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http://www.archive.org/details/manualofpractice1896stev 


A  MANUAL 


PRACTICE  OF  MEDICINE. 

4 


PREPARED 


ESPECIALLY  FOR  STUDENTS. 


BY 

A.  A.  STEVENS,  A.M.,M.D., 

LECTURER  ON  TERMINOLOGY  iMD   INSTRUCTOR  IN   PHYSICAL   DIAGNOSIS   IN  THE  UNIVKR- 
SITY  OF  PENNSYLVANIA  ;  DEMONSTRATOR  OF   PATHOLOGY  IN  THE  WOMAN'S  MED- 
ICAL COLLEGE  OF  PENNSYLVANIA  ;   PHYSICIAN  TO  ST.  AGNES'S  HOSPITAL, 
TO  THE  OUT-PATIENT  DEPARTMENT  OF  THE  EPISCOPAL  HOSPITAL, 
AND  TO  THE  SOUTHEASTERN  DISPENSARY,  PHILADELPHIA. 


"is  an  arch  where  throiijih 

Gleams  that  untravelled  world  whose  margin  fades 
Forever  and  forever  as  we  move." 


FOURTH  EDITION,  REVISED  AXD   ENLARGED. 


ILLUSTRATED. 


PHILADELPHIA: 
W.   B.   SAUNDERS, 

925  Walnut  Street. 

1897,. 


Copyright,  1896. 
By   W.  B.    SAUNDERS. 


PRESS   OF 

W.  B.  SAUNDERS. 


PREFACE  TO  THE  FODRTH  EDITION. 


This  edition  has  been  thoroughly  revised,  and  contains 
some  important  modifications  and  considerable  additions. 
The  articles  on  Malaria,  Dij)htheria,  Empyema,  Chlorosis, 
Pernicious  Anaemia,  Leukaemia,  Scurvy,  and  Myxcedema  have 
been,  for  the  most  part,  rewritten.  An  Appendix  has  also 
been  added,  dealing  with  the  Examination  of  the  Blood  and 
the  Gastric  Contents.  It  is  gratifying  to  note  that  an  Italian 
edition  by  Dr.  Ribolla-Nicodemi  and  Dr.  Cobau  is  now  in 
progress.  The  author  ventures  to  hope  that  the  work  in  its 
present  form  may  be  found  equal  to  existing  requirements, 
and  that  it  may  prove  as  acceptable  to  students  of  medicine 
as  former  editions. 


320  South  16th  Street,  Philadelphia, 
July,  1S96. 


PREFACE  TO  THE  FIRST  EDITION 


Pope  says,  "  Half  our  knowledge  we  must  snatch,  not 
take."  If  this  be  true  of  general  knowledge,  it  is  certainly 
true  of  the  knowledge  of  medicine  as  it  is  taught  in  the  schools 
of  to-day.  In  view  of  this  fact,  there  seems  to  be  a  real  need 
for  books  which  present  their  subjects  in  an  assimilable  form. 

At  the  request  of  many  students  the  author  has  written  this 
book  with  the  hope  that  it  may  serve  as  an  outline  of  Practice 
of  Medicine,  which  shall  be  enlarged  upon  by  diligent  atten- 
dance upon  lectures  and  critical  observation  at  the  bedside. 

In  its  preparation  the  ^mtings  of  the  following  authors 
liave  been  freely  consulted  :  Striimpell,  Osier,  Fagge,  Bristowe, 
Frerichs,  Liebermeister,  Vierordt,  Eichhorst,  Wood,  Poss, 
Gowers,  Sansom,  Henry,  Tyson,  Pepper,  Paul,  Murrell,  Starr, 
Hilton,  Duhring,  Stelwagon,  Van  Harliugen,  Tilbury  Fox, 
Hardaway,  Seiler,  Cohen,  Browne,  Jacobi,  Bruce,  Brunton, 
Charcot,  Dujarden-Beaumetz,  Pavy,  Mitchell,  and  Trousseau. 


CONTENTS. 


Diseases  of  the  Digestive  System. 

PAGE 

General  Symptomatology — 

The  Teeth -.17 

The  Tongue 17 

Fetor  of  the  Breath 18 

The  Appetite 19 

Dysphagia 19 

Vomiting,  or  Emesis  .        .        .        .        •       .  •        .19 

The  Vomit 20 

Acidity  of  the  Gastric  Contents 20 

Hiccough 21 

Abdominal  Pain  and  Tenderness 21 

The  Stools 22 

Abdominal  Distention 23 

Diseases  of  tlie  Mouth,  Tonsils,  Pharynx,  and  (Esophagus — 

Stomatitis 23 

Tonsillitis 26 

Hypertrophy  of  the  Tonsils 28 

Pharyngitis 29 

Spasm  of  the  (Esophagus 32 

Organic  (Esophageal  Obstruction 32 

Diseases  of  the  Stomach — 

Acute  Gastritis     .........  33 

Dyspepsia     .        .        .        , 34 

Atonic  Dyspepsia  =         .         .         „         .         ,         .         .35 

Kervous  Dyspepsia       ........  35 

(V) 


Vi  CONTENTS. 

PAGE 

Catarrhal  D^'^spepsia 37 

Gastralgia 39 

Gastric  Ulcer 40 

Gastric  Cancer 42 

Pyloric  Obstruction  and  Dilatation  of  the  Stomach     .         .  43 

Hffimatemesis 45 

Diseases  of  the  Intestines  and  Peritoneum — 

Constipation .        .        .        '. 45 

Intestinal  Colic 47 

Diarrhcea .         .         .47 

Intestinal  Catarrh 48 

Entero-colitis 51 

Dysentery      .         .         . 52 

Cholera  Morbus 55 

Cholera  Infantum 56 

Typhlitis  and  Appendicitis 58 

Intestinal  Obstruction  ;  Ileus 59 

Animal  Parasitic  Aflections 62 

Peritonitis .         •         .65 

Ascites 67 

Diseases  of  the  Pancreas — 

Pancreatic  Apoplexy 69 

Acute  Pancreatitis 69 

Cirrhosis  of  the  Pancreas 69 

Pancreatic  Calculi        .        .• 69 

Cancer  of  the  Pancreas 69 

Diseases  of  the  Liver —   , 

Area  of  Liver  Dulness 70 

Palpation  of  the  Liver    '     .        .        .         •        ...  70 

Percussion  of  the  Liver 71 

Jaundice,  or  Icterus 71 

Icterus  N'eonatorum 72 

Acholia 73 

Catarrhal  Jaundice 73 

Biliary  Calculi      .        .        .  , 74 

Hypersemia  of  the  Liver 76 

Cirrhosis  of  the  Liver 77 

Abscess  of  the  Liver 80 


CONTENTS.  Vll 

PAGE 

Cancer  of  the  Liver 81 

Amyloid  Liver „         .         .  82 

Hydatid  Cysts  of  the  Liver ,         .  83 

Acute  Yellow  Atrophy  of  the  Liver 84 


Diseases  of  the  Kidneys. 

General  Symptomatology— 

The  Urine „        .        .      85 

Polyuria »        .         .      £5 

Urea .85 

Lithuria 86 

Urates 87 

Leucin  and  Tyrosin 87 

Phosphates .        .88 

Chlorides .89 

Oxaluria .89 

Urobilinuria 90 

Glucosuria,  or  Glycosuria  .......      90 

Albuminuria 92 

Acetonuria 93 

Diaceturia  and  Oxybuturia         ......      93 

Hsematuria .93 

Hfemoglobinuria 94 

Indicanuria 94 

Bile 94 

Chyluria 94 

Pyuria 95 

Diseases  of  the  Kidneys,  and  Pelvis  of  the  Kidney — 

Eenal  Hypersemia 95 

Ursemia 96 

Acute  Nephritis 97 

Chronic  Parenchymatous  Kephritis 99 

Chronic  Interstitial  ISTephritis 100 

Amyloid  Kidney 102 

Eenal  Calculus    .        .        .        .        .        •        •        »        .103 
Pyelitis        ...o        ,..,..     105 


Vlll  CONTENTS. 

PAGE 

Hydronephrosis 106 

Floating  Kidney 107 

Diseases  of  the  Blood. 

General  Symptomatology — 

The  Blood 109 

Oligocythsemia 109 

Leucocytosis 109 

Poikilocytosis 109 

Microcytosis  and  Macrocytosis 110 

Diminished  Haemoglobin 110 

Melansemia ,        .  110 

Lipsemia Ill 

Microoganisms  in  the  Blood Ill 

Angemia,  Scurvy,  Addison's  Disease,  Pm-pura  Hsemorrhagica,  and 
Haemophilia — 

Anaemia Ill 

Symptomatic  Anaemia         .         .         .         .        .        .        .  Ill 

Essential,  or  Primary  Anaemia 112 

Pernicious  Anaemia 112 

Chlorosis 113 

Leucocythaemia    .........  114 

Pseudo-leucaemia 115 

Addison's  Disease        , 115 

Haemophilia 116 

Scurvy          ..........  117 

Purpura  Haemorrhagica      .        , 117 

Diseases  of  the  Circulatory  System. 

General  Symptomatology — 

The  Apex-beat 119 

Displacement  of  the  Apex-beat 120 

Changes  in  the  Force  and  Extent  of  the  Apex-beat  .        .120 

Abnormal  Centres  of  Pulsation           .         .        .         .        .  121 

Jugular  Pulsation 122 

Praecordial  Prominence       .......  122 


CONTENTS. 


IX 


Palpation 

Percussion 

Auscultation        .... 

The  Intensity  of  the  Heart-sounds 

Keduplication  of  the  Heart-sounds 

Adventitious  Sounds,  or  Murmurs 

Hsemic  Murmurs 

Pericardial  Friction-sounds 

The  Aneurismal  Murmur,  or  Bruit 

The  Pulse    . 

Palpitation 

Dropsy 

General  Cyanosis 
Diseases  of  the  Pericardium — 

Pericarditis  . 

Hydro-pericardium 

Hsemo-pericardium 

Pneumo-pericardium  . 
Diseases  of  the  Heart — 

Endocarditis 

Chronic  Valvular  Affections 

Aortic  Stenosis,  or  Aortic  Obstruction 

Aortic  Insufficiency,  or  Aortic  Regurgitation     . 

Mitral  Stenosis,  or  Mitral  Obstruction 

Mitral  Insufficiency,  or  Mitral  Eegurgitation 

Tricuspid  Stenosis,  or  Tricuspid  Obstruction 

Tricuspid  Insufficiency,  or  Tricuspid  Regurgitation 

Pulmonary  Stenosis,  or  Pulmonary  Obstruction 

Pulmonary  Insufficiency,  or  Pulmonary  Regurgitation 

Acute  Ulcerative  Endocarditis 

Acute  Myocarditis 

Fibroid  Heart 

Hypertrophy  of  the  Heart  . 

Dilatation  of  the  Heart 

Fatty  Infiltration  of  the  Heart. 

Fatty  Degeneration  of  the  Heart 

Angina  Pectoris .        .        -        . 


X  CONTENTS. 

PAGE 

Diseases  of  the  Arteries — 

Aneurism  of  tlie  Aorta       ..."...,  148 

Thoracic  Aneurism 149 

Aneurism  of  tlie  Abdominal  Aorta    .....  151 

Arterio-sclerosis 151 


Diseases  of  the  Eespiratort  System. 

General  Symptomatology — 

The  Ked  Nose 

r]#ittening  of  the  Bridge  of  the  ISTose 

Movement  of  the  Alee  I^asi  during  Respiration 

Nasal  Discharge  .... 

The  Sense  of  Smell     . 

Epistaxis 

Spasm  of  the  Laryngeal  Adductors 

Aphonia,  or  Loss  of  Voice 

Paralysis  of  the  Laryngeal  Muscles 

Dyspnoea 

Number  of  Respirations  per  Minute 

Cheyne-Stokes,  or  Tidal-wave  Breathing 

Cough  .        .        .        ... 

Expectoration     .... 

The  Microscopy  of  Sputum 

Inspection  of  the  Chest 

Phthisinoid  Chest 

Rachitic  Chest    .... 

Emphysematous  Chest 

Local  Prominences  and  Depressions 

Expansion  . 

Palpation    . 

Percussion  . 

Auscultation 

Mensuration 
Diseases  of  the  Nose  and  Larynx- 

Coryza         .... 

Chronic  Nasal  Catarrh 

Acute  Catarrhal  Laryngitis 


153 
153 
153 
153 
153 
154 
154 
154 
155 
155 
156 
156 
156 
157 
158 
161 
161 
161 
161 
162 
163 
163 
164 
165 
169 

170 
171 
173 


CONTENTS.  XI 

PAGE 

Chronic  Laryngitis     .        .        .  ^ 174 

Spasmodic  Croup 176 

Membranous  Croup 177 

Laryngismus  Stridulus        .        , 179 

CEdema  of  the  Larynx 181 

Diseases  of  the  Lungs — 

Bronchitis 182 

Dilatation  of  the  Bronchial  Tubes 189 

Asthma 191 

Hay  Asthma 194 

Pulmonary  Emphysema     .        .        .        .        .        .        •  195 

Haemoptysis 198 

Pulmonary  Apoplexy 199 

Congestion  of  the  Lungs    .        • 200 

Croupous  Pneumonia 202 

Catarrhal  Pneumonia ........  207 

Chronic  Interstitial  Pneumonia 211 

Gangrene  of  the  Lung 212 

Abscess  of  the  Lung 213 

CEdema  of  the  Lungs 214 

Pulmonary  Collapse 215 

Pulmonary  Tuberculosis 216 

Diseases  of  the  Pleura — 

Pleurisy 223 

Hydrothorax 227 

Pneumothorax     .         .      • 227 

Hsemothorax o        .        .        .  229 

Pyothorax 229 

Acute  Infectious  Diseases. 

Pever 230 

Period  of  Incubation 233 

Date  at  which  Rashes  Appear 233 

Protection  from  Future  Attacks 234 

Periodic  Remissions  or  Intermissions  in  the  Fever    .         .  234 

Fevers  Associated  with  Jaundice 235 

Termination  by  Crisis .  235 

Subnormal  Temperature ,  235 


CONTENTS. 

PAGE 

Simple  Continued  Fever.    .......  236 

Typhoid  Fever 237 

Typhus  Fever 243 

Kelapsing  Fever          .         ^         .         .         .         .         .         .  245 

Cerebro-spiual  Fever 247 

Malarial  Fever    .        .        .        .        ,        .        .        .        .250 

Scarlet  Fever 256 

Measles 260 

Eotheln 262 

Smallpox 263 

Varicella 266 

Vaccinia 267 

Erysipelas 268 

Yellow  Fever 270 

Acute  General  Tuberculosis 272 

Diphtheria 274 

Whooping-cough 278 

Influenza 280 

Mumps .         .         .         .         .281 

Cholera .  283 

Tetanus 286 

Dengue        ..........  288 

Hydrophobia 288 

Constitutional  Diseases. 


Eheuraatic  Fever 

290 

Chronic  Rheumatism  . 

294 

Muscular  Rheumatism 

295 

Gout     .... 

297 

Rheumatoid  Arthritis 

300 

Rickets 

302 

Lithfemia     . 

303 

Diabetes      .         .         .         . 

304 

Diabetes  Insipidus 

.  ,      . 

308 

CONTENTS. 


Xlll 


Diseases  of  the  Nervous  System. 
Disturbances  of  Motion. 


Paralysis 

Irregular  Paralysis 
Monoplegia 
Hemiplegia 
Paraplegia    . 
Convulsions 

Epileptiform  Convulsions 
Tetanic  Convulsions    . 
Hy steroidal  Convulsions 
Local  Convulsions 
Saltatory  Spasm  . 
Salaam  Convulsions 
Choreiform  Movements 
Athetosis 
Tremors 
The  Gait      . 
The  Eeflexes 
Paradoxical  Contraction 


PAGE 

310 
310 
311 
311 
312 
313 
313 
314 
314 
315 
315 
315 
315 
316 
317 
317 
318 
320 


Disturbances  of  Sensation. 

Anaesthesia 320 

Hemiansesthesia 320 

MonanjBsthesia 321 

Paransesthesia 321 

Hypereesthesia 322 

Parsesthesia 322 

Keuralgia 322 

Muscular  Sensibility    .........  322 

Muscular  Sense 322 

Disturbances  of  Nutrition. 

Muscular  Atrophy 323 

Eeaction  of  Desceneration 323 


XIV  CONTENTS. 

PAGE 

Arthropathies 324 

Myxcedema 324 

Ulceration  Eesulting  from  Perverted  Nutrition         .        .  325 

Disturbances  of  Consciousness. 

Coma 325 

Trance 327 

Somnambulism 327 

Ecstasy 327 

Catalepsy 327 

Disturbances  of  the  Special  Senses. 

The  Eye 327 

The  Ear 328 

PsTCHicAL  Disturbances. 

Delusion 328 

Illusion 329 

Hallucination .  329 

Imperative  Conception 329 

Morbid  Impulse  .........  329 

Delirium 329 

Diseases  of  the  Brain,  Cord,  ISTerves,  and  Muscles. 

Tuberculous  Meningitis 331 

Simple  Leptomeningitis 333 

Chronic  Pachymeningitis 333 

Hemorrhagic  Pachymeningitis 334 

Hydrocephalus     .        .        .        .        .        .        .        .        .  334 

Paretic  Dementia 336 

Cerebral  Paralysis  of  Children 338 

Cerebral  Hypersemia 339 

Cerebral  Anaemia         ........  340 

Cerebral  Hemorrhage 341 

Obstruction  of  the  Cerebral  Arteries          ....  345 

Cerebral  Softening       ........  346 


COl^TENTS.  XV 

PAGE 

Morbid  Growths  in  the  Brain    .         .        ,        .        •        .  347 

Abscess  of  the  Brain 350 

Cretinism 351 

Spinal  Leptomeningitis 352 

Chronic  Spinal  Pachymeningitis 353 

Acute  Myelitis 354 

Chronic  Myelitis 356 

Sclerosis  of  the  Spinal  Cord 357 

Locomotor  Ataxia 357 

Primary  Spastic  Paraplegia 360 

Amyotrophic  Lateral  Sclerosis 361 

Ataxic  Paraplegia       .        . 361 

Disseminated  Cerebro-spinal  Sclerosis         ....  361 

Hereditary  Ataxia 362 

Syringo-myelia 363 

Acute  Anterior  Poliomyelitis 363 

Progressive  Muscular  Atrophy 365 

Bulbar  Paralysis 367 

Acute  Ascending  Paralysis 367 

Caisson  Disease 368 

Idiopathic  Muscular  Atrophy 369 

Pseudo-hypertrophic  Paralysis    .        .        .        .        .        .  370 

Neuralgia 371 

Migraine 374 

Headache 375 

Neuritis 379 

Multiple  Neuritis .381 

Sciatica .382 

Pacial  Paralysis  .        .        . 383 

Epilepsy 385 

Aphasia 387 

Vertigo         . 389 

Meniere's  Disease ^■.        .        .  390 

Hysteria 391 

Neurasthenia      .        . 395 

Chorea .        .  396 

Paralysis  Agitans 398 

Artisan's  Cramp 400 


XVI  CONTENTS. 

PAGE 

Tetany 400 

Thouiseu's  Disease 401 

Exophthalmic  Goitre 402 

Eaynaud's  Disease      ........  403 

Acute  Angio-neurotic  (Edema 404 

Myxcedema 404 

Eacial  Hemi-atrophy 405 

Acromegalia 406 

Sunstroke 407 

Intoxications — 

Alcoholism  .        .  ' *      .        .  408 

Opium-poisoning 411 

Chronic  Lead-poisoning      .        .        .        .        .        .        .  412 

Chronic  Mercurial  Poisoning 413 

Chronic  Arsenical  Poisoning       .         ,         .         .         .         .  413 

DiSEASKS  OF  THE  SeUST  AND  ITS  APPENDAGES. 

General  Symptomatology — 

The  Color  of  the  Skin  . 414 

Hardness,  or  Induration  of  the  Skin 415 

Oedema,  or  Dropsy  of  the  Subcutaneous  Tissues        .         .  416 

Glossy  Skin 116 

Enlargement  of  the  Superficial  Veins 416 

Cutaneous  Emphysema 416 

Abnormal  Conditions  of  the  J^ails 417 

Cutaneous  Eruptions — 

Macules 417 

Purpuric  Spots 418 

Vesicles 420 

Blebs,  or  Bullae 422 

Pustules 422 

Papules       ^ 424 

Tubercles 425 

Wheals,  or  Poraphi 426 

Crusts. .426 

Scales  .        . .427 

Ulcers 428 


CONTENTS.  XVU 

PAGE 

Diseases  of  the  Sweat-glands — 

Anidrosis 430 

Hyperidrosis 430 

Bromidrosis .  431 

Chromidrosis 431 

Sudamen 431 

Functional  Diseases  of  tbe  Sebaceous  Glands — 

Seborrhtjea 432 

Comedo 433 

Milium 434 

Steatoma 435 

Inflammatory  Diseases  of  the  Skin — 

Erythema  Simplex 435 

Erythema  Intertrigo 436 

Erythema  I^odosum    . 436 

Erythema  Multiforme 436 

Urticaria 437 

Herpes  Simplex 438 

Herpes  Zoster 439 

Herpes  Iris 440 

Acne  "Vulgaris 440 

Acne  Eosacea 442 

Furunculus 443 

Carbunculus 444 

Psoriasis 444 

Eczema 446 

Lichen  Euber  and  Lichen  Planus 449 

Prurigo 450 

Dermatitis  Herpetiformis    .......  450 

Dermatitis 451 

Ecthyma      ..........  453 

Pemphigus 454 

Impetigo      ..........  455 

Impetigo  Contagiosa 456 

Miliaria 457 

Atrophic  Affections  of  the  Skin — 

Albinism     . ,        ,  458 

B 


XVIU  CONTENTS. 

PAGE 

Vitiligo 458 

Atrophic  Affections  of  the  Hair  and  ITails        .        .        .  459 

Hypertrophic  Aflections  of  the  Skin — 

Lentigo        ....    - 464 

Chloasma 464 

Keratosis  Pilaris .........  465 

Molluscum  Epitheliale        . 466 

Callositas     ..........  466 

Clavus.        . .  467 

Cornu  Cutaneum         ........  468 

Verruca       ..........  468 

Nsevus 469 

Ichthyosis 469 

Hypertrophic  Affections  of  the  Hair  and  Nails          .         .  470 

Scleroderma .        .  470 

Morphoea 471 

Elephantiasis       .........  471 

Dermatolysis       .........  472 

New  Growths  of  the  Skin — 

Keloid. .  473 

Fibroma 473 

Angioma 474 

Xanthoma 474 

Lupus  Erythematosa 475 

Lupus  Vulgaris 476 

Syphilis  Cutanea 478 

Leprosy 480 

Epithelioma         , 482 

Ainhum 488 

Neuroses  of  the  Skin — 

Dermatalgia 483 

Pruritus 484 

Parasitic  Aflfections  of  the  Skin — 

Tinea  Tricophytina 485 

Tinea  Versicolor 487 

Tinea  Favosa .488 

Scabies 488 

Pediculosis 489 


DISEASES 


DIGESTIVE  SYSTEM. 


THE  TEETH  A^D  GUl^IS. 

Delayed  dentition,  and  the  eruption  of  badly-formed 
teeth,  often  result  from  rickets  or  congenital  syphilis. 

Caries  of  the  teeth  results  from  many  conditions ;  notably, 
an  unnatural  softness  of  the  teeth,  lack  of  cleanliness,  dys- 
pepsia, the  use  of  certain  drugs,  and  diabetes. 

Hutchinson^s  teeth. — The  lateral  incisors  of  the  upper  jaw  \ 
are  pegged,  and  the  central  incisors  of  the  same  jaw  have 
convex  sides,  and  crescentic  notches  on  their  cutting  edges. 
These  peculiarities  indicate  hereditary  syphilis,  and  are  noted 
only  in  the  permanent  teeth. 

A  blue  line  on  the  gums  near  the  insertion  of  the  teeth 
usually  indicates  chronic  lead  poisoning.  Copper  and  silver 
poisoning  occasionally  produce  similar  lines. 

Spongy,  bleeding  gums  are  often  associated  with  scurvy. 
Swelling  of  the  gums  with  tenderness  and  salivation  is  indica- 
tive of  mercurial  poisoning  (ptyalism). 

THE  TONGUE. 

Fur  on  the  tongue. — This  consists  for  the  most  part  of  ac- 
cumulated epithelial  cells,  particles  of  food,  and  microorgan- 
isms, and  results  from  an  elevation  of  temperature  or  from 
disturbed  innervation. 
2 


18  DISEASES   OF   THE   DIGESTIVE  SYSTEif. 

A  Uglit,  uniform  coat  is  often  noted  in  health,  particularly  in 
those  who  sleep  with  the  mouth  open.  Other  causal  condi- 
tions are : — 

(1)  Febrile  diseases. 

(2)  Dyspepsia. 

(3)  Catarrhal  conditions  of  the  nose  and  throat. 
CirGumscribed  furring  often  indicates  local  disturbance,  as  a 

jagged  tooth  or  tonsillitis. 

Unilateral  furring  may  result  from  disturbed  innervation,  as 
in  conditions  affecting  the  second  and  third  branches  of  the 
fifth  nerve.  It  has  been  noted  in  neuralgia  of  those  branches, 
and  in  fractures  of  the  skull  involving  the  foramen  rotuudum. 

The  dry,  brown,  and  fissured  tongue  is  noted  in  low  fevers,  as 
typhoid  fever,  typhoid  pneumonia,  typhoid  dysentery. 

A  red,  beefy  tongue  is  noted  in  certain  febrile  diseases,  as 
typhoid  fever  and  scarlet  fever,  and  in  diabetes. 

The  "■  stratcberry  tongue"  is  characterized  by  a  white  fur, 
through  which  project  bright  red  and  prominent  papillae.  It 
is  seen  in  the  early  stage  of  scarlet  fever. 

A  gray-coated  and  flabby  tongue,  with  an  oval  bare  spot  in 
the  centre,  which  is  red  and  glossy,  is  sometimes  seen  in  chil- 
dren, and  is  indicative  of  gastro-intestinal  catarrh,  or  "mucous 
disease."     (Starr.) 

Tremor  of  the  Toiig^ue. 

Trembling  of  the  tongue  is  noted  in  many  conditions ;  it  is 
peculiarly  marked  in  low  fevers  (typhoid),  in  alcoholism,  and 
in  paretic  dementia. 

Scars  on  the  Tongue. 

8ca7's  on  the  tongue  often  result  from  syphilitic  lesions,  or 
from  the  tooth  wounds  of  epilepsy. 

FETOR  OF  THE  BREATH. 

This  is  often  due  to  local  inflammation,  as  chronic  rhinitis, 
tonsillitis,  etc. ;  to  the  retention  of  decomposing  food,  to  caries 


VOMITING,    OR   EMESIS.  19 

of  the  teeth,  to  certain  lung  diseases,  especially  gangrene  and 
bronchiectasis,  to  dyspepsia,  and  to  the  ingestion  of  certain 
foods  or  drugs. 

THE  APPETITE. 

Boulimia,  or  inordincde  appetite,  is  a  common  symptom  in 
nervous  dyspepsia,  diabetes,  worms,  and  in  certain  insanities, 
notably  in  paretic  dementia. 

Anorexia,  or  loss  of  appetite,  is  a  symptom  common  to  many 
conditions. 

Pica  is  a  craving  for  unnatural  articles  of  food,  and  is  noted  ^ 
particularly  in  chlorosis,  insanity,  pregnancy,  and  worms. 

DYSPHAGIA. 

Dysphagia,  or  difficult  swallowing,  may  result  from :  (1) 
Local  inflammations.  (2)  Stricture  of  the  oesophagus,  spas- 
modic or  organic.  (3)  Paralysis,  local,  as  in  diphtheritic 
paralysis ;  or  centric,  as  in  bulbar  disease. 

VO^nTENG,  OR  EI^IESIS. 

Etiology. — (1)  Toxic,  from  ptomaines,  drugs,  urseraia, 
and  the  specific  fevers.  (2)  Centric  disease,  as  cerebral 
tumors  and  meningitis ;  this  type  is  often  unaccompanied 
with  nausea,  and  does  not  relieve  the  associated  headache. 
(3)  Diseases  of  the  stomach,  as  ulcer,  cancer,  dilatation,  dys- 
pepsia, etc.  (4)  Reflex,  as  from  pregnancy,  uterine  or  ovarian 
disease,  irritation  of  the  fauces,  worms,  biliary  colic,  etc.  (5) 
Intestinal  obstruction,  this  is  often  fecal.  (6)  Disturbed  cere- 
bral circulation,  as  in  swinging  and  sea-sickness.  (7)  Certain 
nervous  aifections,  as  hysteria,  migraine.  (8)  Periodic  vomit- 
ing may  be  in  itself  a  neurosis,  or  may  be  associated  with  the 
gastric  crises  of  locomotor  ataxia.  (9)  OEsophageal  vomiting  \ 
results  from  obstruction,  and  the  vomit  is  alkaline  in  reaction. 


20  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 


THE  VOMIT. 

Watery,  or  mucous  vomit,  is  noted  in  chronic  gastritis,  in 
certain  forms  of  nervous  dyspepsia,  and  after  persistent  emesis, 
as  in  cholera. 

JBilious,  or  green  vomit,  is  not  diagnostic  of  any  sjjecial  con- 
dition ;  it  may  occur  in  any  case  where  vomiting  and  straining 
are  continued. 

Bloody  vomit  {Hcvmatemcsis). — For  cause,  see  page  45. 
When  present  in  large  amount,  it  can  usually  be  recognized 
by  the  unaided  eye;  small  amounts  may  be  detected  by  the 
microscope,  spectroscope,  or  by  chemical  tests. 

Test  for  blood. — Evaporate  some  of  the  filtered  coifee-grounds 
vomit  in  a  watch-glass,  scrape  oif  some  of  the  dried  material ; 
add  a  trace  of  finely -pulverized  salt ;  place  the  mixture  on  an 
object-glass,  and  cover.  Allow  one  or  two  drops  of  glacial 
acetic  acid  to  run  under,  and  again  evaporate ;  when  dry  allow 
one  or  two  drops  of  distilled  water  to  flow  under  to  dissolve 
the  crystals  of  salt.  Under  the  microscope  minute  brown 
rhombic  crystals  of  hsematin  appear. 

Purulent  vomit  may  result  from  the  rupture  of  an  abscess 
into  the  oesophagus  or  stomach,  or  from  phlegmonous  gastritis. 

Feccd  vomit  (stercoraceous)  is  indicative  of  intestinal  obstruc- 
tion.    It  is  recognized  by  its  odor  and  appearance. 

Profuse  vomit. — The  ejection  of  large  quantities  of  frothy 
fermented  material  is  highly  significant  of  gastric  dilatation. 

Vomiting  tcitkout  nausea,  distress,  or  other  phenomena  occurs 
in  certain  neuroses  of  the  stomach,  in  hysteria,  uraemia,  and  in 
brain  disease,  as  tumor,  or  as  a  precursor  of  apoplexy. 

ACIDITY  OF  THE  GASTRIC  CONTENTS. 

Normal  acidity  is  due  to  hydrochloric  acid,  but  other  acids 
are  frequently  formed  during  the  digestive  process,  such  as 
lactic,  butyric,  and  acetic  acids.  The  quautity  of  hydrochloric 
acid  in  normal  gastric  juice  varies  from  0.14  to  0.2-1  per  cent*., 
more  acid  being  secreted  after  a  heavy  meal  than  after  a  light 
one. 


ABDOMINAL   PAIN    AND   TENDERNESS.  21 

Hyperacidity. — This  condition  is  noted  in  chlorosis,  in  gas- 
tric ulcer,  and  in  certain  forms  of  nervous  dyspepsia. 

Subaddity  or  inacidity  occurs  :  (1)  In  certain  nervous  aifec- 
tions,  as  in  some  forms  of  nervous  dyspepsia,  hysteria,  and 
neurasthenia.  (2)  In  extreme  anaemia.  (3)  In  gastric  catarrh. 
(4)  In  gastric  cancer.  (5)  In  acute  febrile  diseases.  (6)  Often 
in  passive  congestion  of  the  stomach,  as  from  chronic  heart  and 
liver  disease. 


RUMIIS^ATIOIV,  OR  MERYCISMUS. 

Rumination  is  a  condition,  rarely  observed  in  man,  in  which 
the  food  is  regurgitated  from  the  stomach  and  subjected  to  a 
second  mastication.  It  is  the  result  of  a  neurosis,  and  is  gen- 
erally found  in  association  with  hysteria,  epilepsy,  neurasthe- 
nia, or  idiocy.  It  is  sometimes  hereditary,  or  acquired  by 
imitation. 

HICCOUGH. 

Hiccough,  or  singultus,  results  from  a  clonic  spasm  of  the 
diaphragm,  and  is  often  noted  as  a  temporary  condition  after 
eating  or  drinking.  Persistent  hiccough  is  sometimes  present  \ 
in  extreme  exhaustion  following  acute  or  chronic  diseases.  It 
results  from  irritation  of  the  phrenic  nerve,  as  from  the  pres- 
sure of  a  thoracic  aneurism.  It  may  be  reflex  from  stomachic, 
hepatic,  intestinal,  or  peritoneal  disease.  It  may  be  due  to 
hysteria. 

ABDOMINAL  PAIN  AND  TENDERNESS. 

Diffuse  abdominal  tenderness  is  noted  in  peritonitis,  in  hys- 
teria, and  in  rheumatism  of  the  abdominal  muscles. 

Persistent  abdominal  pain  results  from  the  various  visceral 
diseases,  chronic  peritonitis,  abdominal  aneurism,  and  disease 
of  the  spinal  vertebrae. 

Colic  is  a  painful  spasm  of  a  mucous  canal.  The  common 
varieties  are — biliary,  intestinal,  renal,  uterine,  and  pancreatic. 


22  DISEASES    OF    THE   DIGESTIVE   SYSTEM. 

Painful  defecation  results  from  constipation,  anal  fissure, 
dysentery,  piles,  ulceration,  stricture,  prolapse  of  the  rectum, 
and  inflammatory  conditions  of  neighboring  organs,  as  the 
uterus  or  prostate  gland. 

THE  STOOLS. 

Blood  in  the  Stools  {Entrorrhagia  or  Mekend). 

The  blood  is  nearly  normal  in  appearance  after  profuse 
hemorrhages,  or  when  it  has  been  quickly  discharged,  as  in 
piles  and  fissure.  Retained  blood  imparts  a  black  or  tarry 
^  appearance  to  the  stools. 

Melsena  results  from  :  (1)  Traumatism.  (2)  Acute  in- 
flammation of  the  bowels,  as  in  enteritis  and  dysentery.  (3) 
Obstructed  circulation,  as  in  chronic  heart  and  liver  disease. 
(4)  Vicarious  menstruation.  (5)  Blood  dyscrasia,  as  in  scurvy, 
purpura,  infectious  fevers,  etc.  (6)  Rupture  of  an  aneurism. 
(7)  Ulcers  in  the  intestines,  as  simple  duodenal  ulcer,  typhoid, 
dysenteric,  tubercular,  or  malignant  ulcers.  (8)  Intussuscep- 
tion. (9)  The  passage  of  blood  from  the  stomach  in  haema- 
temesis.     (10)  Piles,  fissure,  fistula. 

Watery,  or  serous  stools  are  noted  in  choleraic  diseases,  in 
nervous  diarrhoea,  in  the  colliquative  diarrhoea  which  termi- 
nates wasting  diseases,  in  severe  enteritis,  and  in  corrosive 
poisoning,  as  by  arsenic,  antimony. 

Green  stools  may  result  from  an  excessive  amount  of  bile. 
They  are  also  common  in  the  diarrhoeas  of  young  children, 
and  in  these  cases  the  green  color  may  be  due  to  bacterial 
growth.     (Hay  em.) 

Black  stook  may  follow  intestinal  hemorrhage,  and  the  use 
X  of  certain  drugs,  as  charcoal,  bismuth,  iron,  tannin,  etc. 

JRed  stools  usually  indicate  blood,  but  they  may  be  tinged  red 
after  the  administration  of  hsematoxylin  (logwood). 

Mucous  stools  are  noted  in  intestinal  catarrh,  particularly 
when  the  lower  bowel  is  affected,  as  in  entero-colitis  and  dys- 
entery. 

Fatty  stools  result  from  the  ingestion  of  large  quantities  of 
fats,  from  the  absence  of  bile,  and  from  chronic  pancreatic 
diseases. 


STOMATITIS.  '  23 

Purulent  stools  result  from  fistula  in  ano,  dysenteric,  syphi- 
litic, or  malignant  ulceration,  or  the  rupture  of  abscesses  into 
the  bowel,  as  prostatic  and  pelvic  abscesses.  . 

Lienteric  stools. — Stools  which  contain  much  undigested  food 
are  noted  in  inflammatory  conditions  of  the  stomach  and  upper 
bowel. 

ABDOMINAL  DISTENTIOIV. 

Causes. — (1)  Enlargement  of  the  various  organs  from 
tumors  or  other  causes.  Recognized  by  the  history,  irregular 
enlargement,  and  special  symptoms  referable  to  the  organ  af- 
fected. (2)  Ascites.  Recognized  by  movable  dulness  with 
superincumbent  tympany,  and  fluctuation.  (3)  Tympanites. 
Recognized  by  universal  tympany  on  percussion.  (4)  Preg- 
nancy. Recognized  by  suppression  of  menses,  morning  emesis, 
pigmentation  of  mammary  areola,  softening  of  the  cervix,  in- 
termittent uterine  contractions,  etc.  (5)  Distention  of  the 
bladder.  Recognized  by  the  history,  location  of  dulness,  and 
results  of  catheterization. 

STOMATITIS. 

Definition. — Inflammation  of  the  mouth. 

Etiology. — (1)  Mechanical,  chemical,  thermal,  or  parasitic 
irritation.  (2)  Mercurial  poisoning.  (3)  Cachectic  states,  as 
in  phthisis,  cancer,  and  diabetes.  (4)  It  is  most  commonly 
seen  in  young  children  in  association  with  gastro-intestinal 
disturbances,  brought  about  by  artificial  feeding,  warm  weather, 
and  bad  hygienic  surroundings. 

Varieties. — (1)  Catarrhal.  (2)  Aphthous.  (3)  Ulcerative. 
(4)  Parasitic  (thrush).     (5)  Gangrenous.     (6)  Mercurial. 

General  Symptoms. — Heat  and  pain  in  the  mouth,  in- 
creased flow  of  saliva,  fetor  of  the  breath,  restlessness,  languor, 
disinclination  to  nurse,  and  perhaps  some  fever. 

Catarrhal  Stomatitis  {Simple  stomatitis). 

Symptoms. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, a  diifuse  red  swelling  of  the  mucous  membrane. 

Treatment. — Good  hygienic  conditions.     Keep  the  mouth 


24  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

clean.  Employ  a  w^eak  solution  of  boric  acid  or  of  chlorate 
of  potassiuru  as  a  wash. 

Aphthous  Stomatitis  {Follicular  stomatitis,  Vesicular  stom- 
atitis). 

Symptoms. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, numerous  small,  round  vesicles  on  the  cheeks,  lips, 
and  tongue ;  these  vesicles  soon  break,  and  leave  little,  shallow- 
ulcers  with  a  red  areola. 

Prognosis. — Good. 

Treatment. — Sterilize  the  milk.  Nurse  at  regular  inter- 
vals. Wash  the  mouth  with  a  clean  linen  cloth.  Correct 
any  gastric  disturbance.     Use  locally  : — 

^   Acid,  boric,  gr.  x-xx  ; 
Glyceriui,  f5ss; 
Aqufe,  q.  s.  ad  f^ij. — M. 
Chlorate  of  potassium  (gr.  xx-xxx)  may  be  substituted  for  the 
boric  acid. 

Ulcerative  Stomatitis. — This  is  thought  by  some  to  be  an 
infectious  disease,  because  it  often  occurs  in  epidemics,  and 
attacks  both  children  and  adults  when  congregated  and  sub- 
jected to  bad  hygienic  conditions. 

Symptoms. — General  symptoms  of  stomatitis. 

Inspection. — The  gums  of  the  lower  jaw  are  chiefly  affected. 
They  are  swollen,  red,  and  spongy.  Linear  ulcers,  with  gray, 
sloughing  bases  soon  form,  and  may  extend  to  the  cheek.  The 
glands  under  the  jaw  are  swollen.  In  severe  cases  loosening 
of  the  teeth  and  necrosis  of  the  bone  may  follow. 

Prognosis. — Guardedly  favorable. 

Treatment. — Correct  the  hygiene.  Tonic  doses  of  quinine 
by  the  stomach  or  rectum  are  indicated.  Touch  the  ulcers 
with  nitrate  of  silver,  apd  use  as  a  mouth-wash  a  solution  of 
chlorate  of  potassium  or  peroxide  of  hydrogen. 

Parasitic  {Thrush,  Muguet). 

Exciting  Cause. — Saccharomyces  albicans. 

Syi^iptoims. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, numerous  milk-white  elevations  which,  on  removal, 
leave  a  raw  surface.  The  disease  may  extend  to  the  pharynx, 
oesophagus,  and  larynx.  Microscopic  examination  reveals  the 
fungus. 


STOJIATITIS.  25 

Prognosis. — Good. 

Treatment. — Correct  the  hygiene.  Treat  any  gastric  dis- 
turbance. Tonics  are  often  indicated.  Locally,  borax  is  of 
value,  and  may  be  used  in  the  following  mixture : — 

^   Sodii  borat.,  gj  ; 
Glycerini,  f^ij ; 
Aquae,  fovj. — M. 
Sig. — Apply  several  times  daily  by  means  of  a  camel's-hair  brush. 

Gangrenous  Stomatitis  {Cancrum  oris,  Noma). — This  form 
is  usually  seen  in  debilitated  children  between  the  ages  of  two 
and  six  years,  and  usually  follows  one  of  the  specific  fevers, 
especially  measles  and  whooping-cough. 

Symptoms,  —  The  general  symptoms  of  stomatitis  are 
marked. 

Inspection. — The  cheek  is  the  part  affected.  Externally, 
it  is  swollen,  hard,  red,  and  glazed ;  internally,  there  is  noted 
an  irregular,  sloughing  ulcer. 

Complications. — Perforation,  septiesemia,  lobular  pneu- 
monia from  aspirated  sloughs,  and  diarrhcea  from  the  swal- 
lowing of  fetid  material. 

Prognosis. — Grave.  Death  is  common  fi-om  exhaustion 
or  complications.     Recovery  is  often  attended  with  deformity. 

Treatment. — Good  hygiene,  alcoholic  stimulants,  nutri- 
tious food,  tonics  like  iron  and  quinine. 

Locally. — Evert  the  cheek  and  apply  the  actual  cautery,  or 
pack  the  surrounding  parts  with  oiled  lint,  apply  to  the  ulcer 
strong  nitric  acid,  and  subsequently  neutralize  with  bicarbo- 
nate of  sodium.  As  a  mouth-wash,  peroxide  of  hydrogen  is  of 
distinct  value. 

Mercurial  Stomatitis  {Ptyalism). — This  form  of  stomatitis 
is  seen  in  artisans  who  work  in  mercury,  after  the  administra- 
tion of  very  large  doses  of  mercurials,  and  after  the  adminis- 
tration of  small  doses  when  there  has  been  an  unnatural 
susceptibility. 

Symptoms.  Premonitory  Symptoms. — Tenderness  of  the 
gums,  manifested  by  bringing  the  teeth  forcibly  together; 
redness  of  the  gums  near  the  insertion  of  the  teeth,  a  metallic 
taste,  and  an  increase  of  saliva. 


26  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

Later  Symptoms. — Profuse  salivation,  fetor  of  breath,  red- 
ness, swelling,  and  tenderness  of  the  gunas.  The  tongue  may 
be  similarly  affected  and  protrude  from  the  mouth.  In  severe 
cases  ulceration  of  the  mucous  membrane,  loss  of  teeth,  and 
necrosis  of  the  jaw  result. 

Treatment. — Use  astringent  and  antiseptic  mouth-washes. 
Employ  iodide  of  potassium  in  small  doses  to  eliminate  the 
mercury.  Opium  may  be  required  at  night  to  allay  distress. 
Belladonna  aids  in  arresting  the  secretion. 

TONSILLITIS. 

(Amygdalitis.) 

Etiology. — Tonsillitis  occurs  at  all  ages,  but  it  is  particu- 
larly common  in  the  young. 

The  rheumatic  diathesis  exerts  a  predisposing  influence. 
Exposure  to  cold  and  wet  usually  excites  it,  and  such  exposure 
IS  very  effective  when  the  system  is  debilitated,  or  the  throat 
is  congested  from  improper  use  of  the  voice.  Impure  air,  as 
the  effluvium  from  foul  drains  or  sewers,  sometimes  excites  it. 

Varieties. — (1)  Simple,  or  catarrhal.  (2)  Follicular,  or 
lacunar.     (3)  Phlegmonous  (quinsy). 

Symptoms. — Pain  in  the  throat  increased  by  swallowing 
and  talking ;  marked  tenderness  beneath  the  angles  of  the  jaw ; 
and  fever  with  its  associated  phenomena ;  in  severe  forms  the 
temperatui'e  is  quite  high,  104°  or  105°. 

In  the  catarrhal  form  the  tonsils  are  uniformly  swollen,  red, 
and  covered  with  tenacious  mucus. 

In  the  follicular  form  the  tonsils  are  red  and  swollen,  and 
present  little  yellow  spots  on  their  surfaces.  These  spots  are 
found  to  be  plugs  of  degenerated  epithelium  which  are  retained 
in  the  crypts  on  account  of  the  swelling  and  occlusion  of  their 
outlets.  These  plugs  are  often  expectorated  during  convales- 
cence as  offensive  cheesy  pellets.  • 

In  the  phlegmonous  form  the  tonsils  are  extremely  swollen, 
often  so  much  that  they  almost  meet;  the  pain  is  intense  and 
of  a  throbbing  character.  One  gland  soon  becomes  larger 
than  the  other,  softens,  fluctuates,  and  turns  yellow  from  sup- 
puration. Swallowing  is  almost  impossible,  the  voice  is  lost, 
and  breathing  is  difficult. 


TONSILLITIS.  27 

Diagnosis. — In  children  tonsillitis  may  resemble  scarlet 
fever,  especially  when  the  former  is  associated  with  an  acci- 
dental rash. 

Scarlet  Fever. — History  of  contagion,  onset  with  vomiting, 
a  punctated  red  rash,  "  strawberry"  tongue,  albuminuria,  and 
pulse  too  rapid  to  be  proportionate  to  the  fever. 

Diphtheria. — The  follicular  form  resembles  diphtheria,  but 
in  the  latter  there  is  a  false  membrane,  not  only  on  the  tonsils 
but  on  surrounding  parts,  and  its  removal  leaves  behind  a 
raw  surface.  The  history  of  contagion,  the  rapid,  w^eak  pulse, 
the  marked  swelling  of  the  submaxillary  glands,  albuminuria, 
and  the  Klebs-Loffler  bacillus,  detected  by  cultivation,  will 
also  indicate  diphtheria. 

Prognosis. — Favorable  ;  even  in  grave  cases  rupture  of  the 
abscess  occurs  when  death  seems  imminent.  Suifocation  from 
rupture  during  sleep,  and  death  from  ulceration  of  the  carotid 
artery  are  extremely  rare  terminations. 

Treatment. — Rest,  light  diet,  and  protection.  In  the 
beginning,  salicylate  of  sodium  (gr.  xx  thrice  daily)  may  be 
given  to  shorten  the  attack.  The  ammoniated  tincture  of 
guaiacum  (5ij  every  two  hours)  is  a  very  efficient  remedy. 
The  benzoate  of  sodium  is  also  highly  recommended  : — 

]^   Sodii  benzoat.,  Sj-^iv  ; 

Glycerin.,  "^ 

Elix.  calisay.,  aa  f^j. — M. 
Sig. — :A  teaspoonful  every  hour  or  two. 

In  some  cases  quinine  (gr.  v.  thrice  daily)  with  small  doses 
of  the  tincture  of  aconite  and  the  tincture  of  belladonna  is 
an  efficient  remedy. 

In  severe  cases  opium  is  often  required  to  relieve  pain  and  to 
produce  sleep. 

Local  Treatment  {Internal). — Pellets  of  ice  give  much  relief. 
The  following  remedies  are  efficient :  Solutions  of  nitrate  of 
silver,  dry  bicarbonate  of  sodium,  guaiac  lozenges  (gr.  ij), 
saturated  ethereal  solution  of  iodoform.     Or : — 

^   Potass,  chlor. ,  gr.  xx-xxx  ; 
Tinct.  ferri  chlor., 
Glycerin.,  aa  fgss  ; 
Aqute,  q.  s.  ad  f.|ij. — M. 
Sig. — Apply  several  times  daily  with  a  camel's-hair  brush. 


28  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

When  the  glands  are  very  much  swollen  scarification  will 
lessen  the  pain  and  often  shorten  the  attack.  When  fluctua- 
tion is  detected  the  tonsil  should  be  incised  with  a  guarded 
bistoury. 

External  Ajpplieations. — An  ice-bag,  a  poultice,  or  iodine. 

HYPERTROPHY  OF  THE  TONSILS. 

Etiology. — Childhood,  the  rachitic  and  tubercular  dia- 
theses, and  repeated  attacks  of  acute  tonsillitis  are  the  predis- 
posing causes.     It  may  arise  without  obvious  cause. 

Pathology.^ — It  may  be  a  true  hypertrophy,  but  in  most 
instances  either  the  glandular  structure  or  the  connective 
tissue  predominates ;  and  the  firmness  of  the  gland  increases 
in  proportion  to  the  overgrowth  of  the  latter.  The  follicles 
are  often  dilated,  and  filled  with  cheesy  material  which  results 
from  the  accumulation  of  fatty-degenerated  epithelium.  Naso- 
pharyngeal catarrh  and  adenoid  growths  in  the  naso-pharynx 
are  often  associated  conditions. 

Symptoms. — Difficult  swallowing,  mouth-breathing,  snor- 
ing during  sleep,  a  thick  voice  with  a  nasal  twang  to  it,  and 
malnutrition.  Sufferers  are  very  prone  to  acute  attacks  of 
catarrh  of  the  nose  and  throat.  In  severe  cases,  from  inter- 
ference with  breathing,  the  chest  assumes  the  rachitic  type — 
that  is,  flattened  at  the  sides  and  base  and  prominent  over  the 
sternum. 

Peognosis. — Favorable  under  prolonged  and  careful  treat- 
ment. 

Treatment.  General  Treatment. — Build  up  the  tone  of  the 
patient  by  frequent  bathing  with  salt  water,  followed  by  fric- 
tion, light  gymnastics,  deep  breathing,  and  by  the  use  of 
nutrient  tonics  such  as  cod-liver  oil,  hypophosphites,  and 
iodide  of  iron. 

Local  Treatment. — A  solution  of  nitrate  of  silver,  or  Lugol's 
solution  (liquor  iodi  compositus),  may  be  applied  frequently  to 
the  tonsils;  or  dilute  acetic  acid  (gtt.  ij)  or  a  dilute  solution 
of  iodine  (gtt.  ij)  may  be  injected  into  the  tonsils.  When  the 
glands  are  very  large  they  should  be  removed  by  the  tonsil- 
lotome,  scissors,  or   galvano-cautery.       Pharyngeal   adenoids 


PHARYNGITIS.  29 

should  likewise  be  removed  by'  the  finger-nail  or  curette 
while  the  patient  is  under  the  influence  of  some  general  anaes- 
thetic, or  after  the  parts  have  been  treated  with  cocaine. 

PHARYIVGITIS. 

Acute  Pharyngitis  (Acute  " sore  throat"  Simjyle  angina). 

Definition. — An  acute,  catarrhal  inflammation  of  the 
mucous  membrane  of  the  pharynx,  soft  palate,  and  uvula,  and 
frequently  associated  with  tonsillitis  and  laryngitis. 

Etiology. — Exposure  to  cold  and  wet,  especially  when  the 
system  is  debilitated  or  the  throat  is  congested  from  improper 
use  of  the  voice.  It  may  be  rheumatic  in  origin.  It  may  be 
excited  by  local  irritants,  such  as  hot  drinks  or  the  inhalation 
of  noxious  gases. 

Exposure  to  infectious  fevers,  like  scarlatina  and  measles, 
may  be  followed  by  simple  pharyngitis. 

Symptoms. — Chilliness  and  slight  fever  with  its  associated 
phenomena;  soreness  in  the  throat,  painful  deglutition,  a  sen- 
sation of  dryness  or  tickling,  with  a  hacking  cough  ;  stiifness 
and  tenderness  of  the  muscles  of  the  neck.  Extension  to  the 
larynx  may  cause  hoarseness ;  to  the  ear,  through  the  Eusta- 
chian tube,  deafness.  Inspection  reveals  a  red  and  swollen 
mucous  membrane. 

Varieties. — (1)  Simple;  recognized  by  the  above  symp- 
toms. (2)  Rheumatic  ;  recognized  by  the  history,  intense  pain, 
and  stiffness  of  the  muscles,  without  much  change  in  the  local 
appearance.  (3)  Follicutar ;  the  mucous  membrane  is  red, 
swollen,  and  covered  with  whitish  spots  which  represent  re- 
tained secretion  in  the  inflamed  follicles.  (4)  Infectious  pharyn- 
gitis is  the  form  associated  with  the  infectious  fevers. 

Prognosis. — Favorable. 

Treatment. — Light  diet  and  avoidance  of  exposure.  Hot 
drinks,  followed  by  Dover's  powder  (gr.  x),  and  a  saline  purge 
will  sometimes  abort  it. 

Tincture  of  aconite  (gtt.  ij)  with  tincture  of  belladonna  (gtt. 
v)  every  two  hours  is  sometimes  useful.  In  the  rheumatic 
form  the  salicylate  or  benzoate  of  sodium  is  very  efficient. 


30  DISEASES   OP   THE   DIGESTIVE  SYSTEM. 

In  simple  angina  Pepper  recommends  : — 

^  Potass,  chlorat.,  3iss-ij  ; 
Potass,  bromid.,  sss; 
Ext.  belladonufe,  gr.  iij-v  ; 
Syr.  limonis,  f.^j  ; 
Syrupi,  q.  s.  ad  f^iv. — M. 
Sig. — Teaspoonful  thrice  daily. 

Local  Remedies. — A  steam  spray,  pellets  of  ice,  a  gargle 
of  chlorate  of  potassium  (gr,  x  to  f  oj),  the  application  of  a 
solution  of  nitrate  of  silver  (gr.  v  to  fsj),  or  lozenges  of 
cocaine,  chloride  of  ammonium,  or  chlorate  of  potassium. 

Chronic  Pharyngitis. 

Etiology. — Chronic  "  sore  throat"  usually  results  from  re- 
peated acute  attacks,  improper  use  of  the  voice,  or  the  con- 
tinuous action  of  irritants,  like  tobacco  smoke. 

Varieties. — (1)  Hypertrophic.  (2)  Atrophic.  (3)  Ulcer- 
ative.    (4)  Phlegmonous. 

Symptoms. — The  voice  is  husky  and  its  use  is  followed  by 
distress  ;  secretion  is  increased  so  that  there  is  a  constant  desire 
to  clear  the  throat ;  disagreeable  sensations,  as  fulness,  tickling, 
and  the  like,  are  frequently  noted. 

In  the  hypertrophic  form  (granular  sore  throat,  clergyman's 
sore  throat,  chronic  follicular  pharyngitis)  the  mucous  mem- 
brane is  thick,  swollen,  traversed  by  dilated  veins,  and 
studded  with  numerous  elevations  which  are  composed  of  dis- 
tended follicles  and  overgrown  lymphatic  tissue. 

In  the  atrophic  form  (Pharyngitis  Sicca),  the  mucous  mem- 
brane is  pale,  smooth,  glossy,  and  dry. 

Ulcerative  Pharyngitis. — Ulceration  may  be  due  to  simple 
inflammation,  syphilis,  tuberculosis,  cancer,  and  lupus. 

Phlegmonous  Pharyngitis  (^Retropharyngeal  abscess). — Sujj- 
purative  inflammation  of  the  retropharyngeal  connective  tissue 
may  occur  as  a  sequel  to  one  of  the  infectious  fevers,  or  may 
be  due  to  caries  of  the  cervical  vertebrae,  or  to  the  impaction 
of  a  foreign  body. 

It  may  be  recognized  by  sore  throat,  weak  voice,  difficult 
deglutition,  and  the  results  of  a  digital  examination. 

Treatment. — Chronic  pharyngitis  does  not  result  so  much 


STENOSIS   OF  THE   (ESOPHAGUS.  31 

from  excessive  use  of  the  voice  as  from  its  improper  use,  and 
until  this  is  corrected  no  treatment  will  be  successful.  Pa- 
tients should  be  instructed  to  expel  sounds  by  the  aid  of  the 
diaphragm  and  abdominal  muscles,  instead  t)f  the  muscles  of 
the  throat  and  larynx.  The  habit  of  hawking  and  scraping 
to  clear  the  throat  must  be  rigidly  interdicted.  The  patient 
must  guard  against  mouth-breathing.  Sponging  the  neck 
night  and  morning,  first  with  tepid,  then  with  cold  water,  will 
render  the  throat  less  sensitive.  The  general  health  will  re- 
quire attention,  and  such  tonics  as  iron,  quinine,  strychnine 
may  be  very  useful. 

Local  treatment. — The  naso-pharynx  should  be  kept  clean 
by  frequent  spraying  or  douching  with  some  antiseptic  solu- 
tion like  the  following  : — 

^   Sodii  bicarb., 

Sodii  biborat.,  aa  gr.  xx  ; 

Acid,  carbolic,  gtt.  vj  ; 

Glycerin.,  fsvj  ; 

Aquse,  q.  s.  ad  f^vj. — M.     (Dobbll.) 

The  nasal  chambers  should  be  inspected  and  any  existing 
disease  treated. 

Astringent  applications  are  often  useful ;  solutions  of  nitrate 
of  silver,  five  or  ten  per  cent.,  sulphate  of  zinc,  or  tannic 
acid,  ten  to  twenty  per  cent.,  may  be  employed  for  this  pur- 
pose. Lymphatic  hypertrophies  should  be  removed  by  the 
galvano-cautery. 

Retropharyngeal  abscesses  will  require  evacuation  and  treat- 
ment directed  to  the  cause. 

Ulcerative  pharyngitis  will  require  appropriate  constitu- 
tional treatment,  and  such  local  remedies  as  nitrate  of  silver, 
iodoform,  nitric  acid,  etc. 

STENOSIS  OF  THE  (ESOPHAGUS. 

Varieties. — (1)  Functional  obstruction,  due  to  spasm 
(oesophagismus).     (2)  Organic  obstruction. 


32  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 


SPASM  OF  THE  (ESOPHAGUS. 

Etiology. — Female  sex  ;  nervous  temperament ;  hysteria ; 
reflex  irritation.  It  may  occur  as  a  symptom  of  hydrophobia, 
tetanus,  and  organic  oesophageal  obstruction. 

Symptoms  of  Simple  CEsophageal  Spasm. — Paroxysmal 
dysphagia,  often  associated  with  a  sense  of  constriction  in  the 
chest ;  little  or  no  loss  of  flesh.  An  oesophageal  bougie  can 
be  passed  without  much  difficulty. 
^  Diagnosis. — The  age  and  sex  of  the  patient,  the  parox- 
ysmal character  of  the  obstruction,  the  ability  to  pass  a  bougie, 
the  absence  of  wasting,  and  the  absence  of  any  other  cause, 
will  serve  to  separate  it  from  organic  obstruction. 

Prognosis. — Good  for  life,  but  indefinite  as  regards  dura- 
tion. 

Treatment. — Search  for  some  exciting  cause  and  remove 
it  when  possible.  The  treatment  is  largely  dietetic,  hygienic, 
and  moral.  Tonics  like  iron,  arsenic,  and  quinine  are  often 
indicated,  and  may  be  combined  with  such  antispasmodics  as 
valerian,  asafoetida,  or  sumbtd.  The  systematic  passage  of  a 
bougie  may  be  of  "great  value.  A  mild  electrical  current  may 
be  applied  through  the  bougie. 

ORGANIC  (ESOPHAGEAL  OBSTRUCTION. 

Etiology. — (1)  An  external  tumor  pressing  on  the  oesoph- 
agus. This  is  most  commonly  an  aneurism.  (2)  A  tumor 
growing  from  the  oesophageal  wall ;  generally  a  cancer.  (3) 
A  cicatrix,  from  ulceration.  The  ulcer  may  be  due  to  syph- 
ilis or  to  some  corrosive  poison,  as  a  strong  acid  or  alkali. 
(4)  A  foreign  body. 

Symptoms. — A  slowly  increasing  difficulty  in  deglutition, 
with  the  regurgitation  of  food.  The  oesophagus  is  often  much 
dilated  above  the  constriction,  and  the  food  may  collect  in  the 
pouch  thus  formed,  so  that  regurgitation  may  be  delayed  for 
several  hours.  The  passage  of  a  bougie  meets  with  a  perma- 
nent obstruction.     There  is  much  loss  of  flesh. 

Diagnosis. — The  history  of  syphilis  or  corrosive  poisoning 
will  suggest  a  cicatrix.     Aneurismal  obstruction  can  usually 


ACUTE   GASTRITIS.  33 

be  detected  by  physical  examination.  Aneurism  should  be 
excluded  before  a  bougie  is  passed.  The  age,  cachexia,  pain, 
and  involvement  of  other  organs  will  indicate  cancer. 

Prognosis. — Depends  on  the  cause.  It  is  unfavorable  in 
aneurism  and  cancer.  In  cicatricial  contraction  the  obstruc- 
tion may  be  overcome  for  an  indefinite  period. 

Treatment. — Aneurism  :  Prolonged  rest,  restricted  diet, 
and  potassium  iodide.  Cicatricial  contraction  :  Systematic  dil- 
atation with  graduated  bougies.  Cancer :  In  the  early  stage, 
the  cautious  use  of  a  bougie  is  advisable.  In  advanced  cases 
the  patient  may  be  fed  through  a  tube,  and  wdien  this  is  no 
longer  possible,  life  may  be  prolonged  for  a  short  time  by 
rectal  alimentation  or  by  feeding  through  a  gastric  fistula. 

ACUTE  GASTRITIS. 

(Acute  Gastric  Catarrh.) 

Etiology. — (1)  Ingestion  of  indigestible  food,  especially 
when  followed  by  exposure  to  cold  and  wet.  (2)  Toxic  sub- 
stances in  excess,  as  alcohol,  strong  acids,  and  alkalies.  (3)  It 
is  an  associated  condition  in  certain  infectious  diseases,  as  yel- 
low fever,  measles,  and  scarlet  fever. 

Pathology. — The  mucous  membrane  is  red,  swollen,  and 
covered  with  thick  mucus.  It  is  sometimes  the  seat  of  ecchy- 
moses. 

Symptoms. — The  symptoms  vary  much  in  degree.  In  se- 
vere cases  there  may  be  moderate  fever  (102°-103°)  and  its  asso- 
ciated phenomena,  with  anorexia,  coated  tongue,  intense  pain 
in  the  epigastrium,  which  is  tender  to  the  touch,  persistent 
vomiting,  thirst,  and  considerable  prostration.  Jaundice  may 
follow  from  the  extension  of  the  catarrh  to  the  bile-ducts,  and 
diarrhoea  from  its  extension  to  the  intestines. 

Diagnosis. — It  may  resemble  the  onset  of  scarlet  fever,  but 
the  history  of  contagion,  the  "  strawberry  tongue,"  sore  throat, 
very  rapid  pulse,  and  eruption,  cliaracterize  the  latter. 

Prognosis. — Usually  favorable ;  it  rarely  lasts  more  than  a 
few  days. 

Treatment. — Absolute  rest.  If  the  stomach  has  not  been 
completely  emptied,  an  emetic  such  as  ipecac  may  be  employed. 


34  DISEASES   OP  THE   DIGESTIVE  SYSTEM. 

Locally,  a  mustard  plaster  or  a  turpentiue  stupe  will  aid  in 
relieving  the  distress.  In  severe  cases  no  food  should  be 
given  by  the  mouth  until  the  stomach  becomes  retentive. 
Thirst  should  be  allayed  with  cracked  ice.  Later,  milk  with 
lime-water  (a  teaspoonful  of  each)  may  be  given  hourly,  and 
this  may  be  followed  by  light  broths  in  similar  quantities. 

Persistent  vomiting  may  be  relieved  by  small  doses  of  calo- 
mel (gr.  -^^),  bismuth  (gr.  v.-x.),  carbolic  acid  (gtt.  i-^),  or 
wine  of  ipecac  (gtt.  1 ). 

^  Hydrarg.  chlor.  mitis,  gr.  j  ; 
Bismuth,  subuit.,  5j.— M. 
Ft.  in  chart.  No.  xij. 
Sig.— One  every  hour. 

Or, 

^  Creosoti,  gtt.  iij  ; 

Bismuth,  subnit.,  3j. — M. 
rt.  in  chart.  No.  xij. 
Sig. — One  every  hour. 

Or, 

]^   Vin.  ipecac, 

Tinct.  nucis  vom.,  aa  fgj. — M.     (Pepper.) 
Sig. — Two  drops  in  water  every  two  hours. 

Severe  pain  and  obstinate  vomiting  will  often  yield  to  opium, 
in  the  form  of  suppositories.     Thus  : — 

l^i  Pulv.  opii,  gr.  vj  ; 

01.  theobrom,,  q.  s. — M. 
Ft.  in  suppos.  No.  vj. 
Sig. — One  every  three  hours. 

Toxic  gastritis  will  require  in  addition  appropriate  anti- 
dotes. 


DYSPEPSIA. 

Definition. — The  word  dyspepsia  means  ill  digestion,  and 
is  applied  to  a  group  of  symptoms  which  accompanies  every 
disease  of  the  stomach  ;  when,  however,  the  symptoms  depend 
on  nothing  more  than  simple  atony,  hypersensitiveness,  or 
chronic  catarrh,  the  patient  is  said  to  have  dyspepsia. 

Corresponding   to   these   conditions,    three   varieties    have 


DYSPEPSIA.  35 

been  recognized,  viz. :  (1)  Atonic.  (2)  Nervons,  and  (o) 
Catarrhal  dyspepsia. 

Etiology. — (1)  Heredity.  (2)  All  visceral  diseases,  as 
heart,  liver,  and  kidney  disease.  (2)  Overwork,  mental  or 
physical.  (4)  Gastric  irritants,  as  tea,  coffee,  and  alcohol  in 
excess.  (5)  Dietetic  errors,  which  include — iusufficient  mas- 
tication from  bad  teeth  or  hurried  eating,  too  much  food,  in- 
sufficient food,  coarse  or  improperly  cooked  food,  excessive 
dilution  of  food  with  liquids,  excess  of  condiments,  and  irreg- 
ular eating. 

Symptoms  of  Dyspepsia. — Coated  tongue,  perverted  ap- 
petite, fulness  and  distress  after  eating,  eructations,  flatulence, 
"  heart-burn,"  palpitation,  headache,  vertigo,  disturbed  sleep, 
and  lassitude. 


ATONIC  DYSPEPSIA. 

Characteristic  Symptoms. — The  tongue  is  pale,  coated, 
flabby,  and  tooth-marked  ;  the  appetite  is  lost ;  there  is  a  sense 
of  fulness  and  distress  over  the  stomach,  some  time  after  eating, 
without  actual  pain  or  tenderness.  The  bowels  are  constipated. 
There  is  much  flatulence.  The  patient  is  pale,  the  muscles 
are  soft,  the  pulse  is  weak,  and  there  is  great  lassitude. 

Prognosis. — Good. 

Treatment. — The  diet  must  be  carefully  regulated,  and 
rich  and  heavy  food  rigidly  interdicted.  The  hygienic  sur- 
roundings must  be  so  modified  that  the  general  condition  of 
the  patient  will  be  improved.  Tonics  like  iron,  quinine,  and 
strychnine  are  often  indicated.  Dilute  mineral  acids  with^ 
pepsin  will  be  required  to  assist  the  digestive  process. 

Purgatives  should  be  avoided,  and  constipation  relieved  by 
diet,  mineral  waters,  enemas,  or  suppositories. 

NERVOUS  DYSPEPSIA. 

This  type  usually  occurs  in  those  of  a  distinctly  nervous 
temperament,  and  excessive  mental  strain  and  dietetic  errors 
are  potent  etiological  factors. 


36  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Characteristic  Symptoms. — The  tongue  is  often  clean. 
The  appetite  is  very  irregular — at  one  time  it  is  lost ;  at  an- 
other it  is  inordinate;  at  another  it  is  perverted,  tlie  patient 
craving  an  unnatural  diet.  Severe  pain  is  a  prominent  symp- 
tom which  is  apt  to  appear  when  the  stomach  is  empty,  and 
to  be  relieved  by  eating.  The  term  gastralgia  is  applied  to 
this  pain.  Vomiting  is  not  common,  but  it  may  occur  when 
the  stomach  is  full  or  empty.  The  gastric  acidity  may  be 
normal  or  subnormal,  but  it  is  often  excessive. 

Other  nervous  phenomena  are  commonly  present,  such  as 
headache,  vertigo,  disturbed  sleep,  hypochondriasis,  neuralgia, 
palpitation,  and  perverted  sensations. 

Diagnosis. — The  history,  associated  nervous  phenomena, 
the  time  that  the  pain  appears,  the  periods  of  complete  relief, 
the  absence  of  hemorrhage,  cachexia,  tumor,  and  local  tender- 
ness, are  the  chief  diagnostic  points. 

Prognosis. — Good,  when  the  cause  can  be  removed  and 
the  patient  thoroughly  controlled. 

Treatment. — The  avoidance  of  excitement  and  excessive 
mental  work  must  be  enjoined.  An  extended  voyage  may 
effect  a  cure.  In  brain-workers  the  value  of  regular  physical 
exercise  and  frequent  bathing,  followed  by  friction  of  the  skin, 
cannot  be  overestimated.  On  the  other  hand,  the  ansemic  and 
exhausted  may  require  the  "  rest-cure."  The  patient's  experi- 
ence will  assist  in  the  regulation  of  the  diet.  Tonics  like  iron, 
arsenic,  quinine,  and  strychnine  are  often  indicated.  Elec- 
tricity applied  to  the  stomach  has  given  good  results.  Pepsin 
and  mineral  acids  will  be  of  service  only  in  those  cases  in 
which  examination  reveals  a  lack  of  acid  in  the  gastric  juice. 
In  such  cases  Dj".  Pepper  recommends  : — 

]^   Quiniuse  sulph.,  gr.  xxxij  ; 
Strychninse  sulph.,  gr.  ss  ; 
Aeicl.  hydrochlor.  dil.,  fgij. 
vel     Acid,  phosphor,  dil. ,  f^iij  ; 
Tr.  cardamom,  comp.,  f^ij  ; 
Aquae,  q.  s.  ad  f^iv. — M.     Filter. 
Sig. — Teaspoonful  after  meals. 


CATAERHAL   DYSPEPSIA.  37 

CATARRHAL  DYSPEPSIA. 

(Chronic  Gastritis,  Chronic  Gastric  Catarrh.) 

Catarrh  of  the  stomach  is  often  a  primary  condition  result-^ 
ing  from  the  ordinary  causes  of  dyspepsia,  but  its  frequent 
dependence  on  disturbed  circulation  from  heart,  lung,  and  liver 
disease  should  never  be  forgotten. 

Pathology. — In  the  early  stages  the  mucous  membrane 
is  ashy-gray  in  color  and  covered  with  tenacious  mucus. 
Ecchymoses  are  often  noted.  Microscopic  examination  re- 
veals degeneration  of  the  glandular  epithelium  and  an  over- 
growth of  the  connective  tissue.  In  advanced  cases  the  walls 
may  be  thin  from  extreme  atrophy  of  the  glandular  structure, 
but  more  often  they  are  thick,  wrinkled,  and  indurated  from 
excessive  overgrowth  of  connective  tissue. 

Characteristic  Symptoms. — The  tongue  is  irregularly 
coated,  the  tip  often  red,  and  the  papillse  enlarged.  The  ap- 
petite is  variable.  After  eating  there  is  weight  and  distress, 
and  often  diffuse  tenderness  on  palpation.  There  are  fre- 
quent eructations  of  wind  and  sour  liquid. 

Nausea  and  vomiting  are  frequently  present ;  the  latter  may 
occur  in  the  morning  on  rising,  and  the  ejected  material  be 
composed  of  the  frothy  mucus  which  has  collected  in  the 
stomach  during  the  night,  or  it  may  occur  some  time  after 
eating,  and  be  composed  of  partially-digested  food  mixed  with 
acids  of  fermentation,  such  as  lactic,  butyric,  and  acetic  acids. 
The  normal  acid,  hydrochloric,  is  invariably  diminished  or 
absent.  The  bowels  are  constipated,  and  the  urine  is  scanty 
and  throws  down  a  heavy  deposit  of  urates  or  phosphates. 
The  nervous  phenomena  common  to  all  forms  of  dyspepsia  are 
present. 

Protracted  cases,  with  atrophy  of  the  gastric  tubules,  present 
the  symptoms  of  pernicious  ansemia. 

Diagnosis.  Cancer. — After  forty,  hsematemesis,  cachexia, 
tumor,  the  short  duration,  and  the  involvement  of  other  organs. 

Ulcer. — Hsematemesis,  sharp  pain  increased  by  eating,  vomit- 
ing soon  after  eating,  local  tenderness,  abundance  of  hydro- 
chloric acid. 


N 


38  DISEASES   OF   THE   DIGESTIVE  SYSTEM, 

Care  must  be  taken  to  determine  whether  the  catarrh  is 
primary  or  secondary  to  visceral  disease. 

Prognosis. — When  not  dependent  on  organic  disease  of 
other  viscera,  the  prognosis  is  good. 

Treatment. — Good  hygienic  conditions.  A  regulated 
diet ;  in  severe  cases  an  absolute  skimmed-milk  diet,  or  par- 
tially-digested foods.  Thick  mucus  and  undigested  food  may 
be  removed  by  the  stomach-tube  when  its  introduction  is  well 
borne.  Pure  or  slightly  alkaline  water  may  be  employed  ; 
but  when  there  is  much  fermentation,  one  per  cent,  of  salicylic 
acid  may  be  added  with  advantage.  Irrigation  should  be 
practised  daily,  or  every  other  day,  preferably  before  break- 
fast, and  the  tube  should  be  kept  in  position  until  the  escap- 
ing fluid  is  quite  clear. 

When  lavage  is  not  well  borne,  the  patient  may  be  directed 
to  sip  before  breakfast  a  half  pint  of  some  hot  alkaline  water, 
such  as  Carlsbad.  This  is  especially  indicated  when  there  is 
constipation. 

Artificial  Carlsbad  salt : — 

^  Sodii  sulph.,  ^v; 
Sodii  bicarb.,  gij  ; 
Sodii  chlorid.,  gj.— M.     (Welch.) 
Sig. — 3j  in  a  half  pint  of  water  half  hour  before  breakfast. 

Dilute  hydrochloric  acid  is  nearly  always  indicated,  and  it 
may  be  combined  advantageously  with  pepsin. 

^   Tinct.  nucis  vera.,  f.^ss  ; 
Acid,  hydrochlor.  dil.,  f^ij  ; 
Pepsin.,  3iij; 

Aqufe,  q.  s.  ad.  fjiv. — M. 
Sig. — A  teaspoonful  after  meals. 

The  catarrhal  process  is  often  favorably  influenced  by  sub- 
nitrate  of  bismuth,  or  nitrate  of  silver.  When  tJiere  is  much 
fermentation  and  flatulence,  salicylate  of  strontium  (gr.  v-x), 
or  subnitrate  of  bismuth  with  some  antiferment  may  be 
employed. 

^   Salol,  gr.  xl ; 

Bismuth,  subuitrat.,  gss. — M. 
Ft.  in  chart.  Ko.  xx. 
Sig. — One  powder  half  an  hour  before  meals. 


GASTRALGIA.  39 

Instead  of  salol,  creosote  (gtt  J)  may  be  added  to  each  powder. 
Constipation  should  be  relieved  by  diet,  mineral  waters, 
enemas,  suppositories  of  glycerin  or  gluten,  or  by  mild  laxa- 
tives. Acid  eructations  and  "  heart-burn"  may  be  relieved  by 
digestants  and  dilute  acids,  taken  immediately  after  meals ;  or 
by  alkalies,  with  or  without  such  antiferments  as  creosote, 
salol,  or  naphthol,  taken  one  or  two  hours  after  meals. 

OASTRALGIA. 

(Gastrod3niia,  Neuralgia  of  the  Stomach.) 

Definition. — A    painful    paroxysmal    affection    of    the  N 
stomach,  unassociated  with  any  organic  lesion.  \ 

Etiology. — Nervous  temperament,  overwork,  anseraia,  and 
dietetic  errors  are  the  predisposing  causes. 

Symptoms. — Paroxysms  of  severe  pain  in  the  epigastrium, 
usually  radiating  to  the  back,  occurring  when  the  stomach  is 
empty,  and  relieved  by  pressure  and  the  ingestion  of  food  or 
warm  stimulating  drinks. 

Diagnosis.  Gastric  Ulcer. — In  this  disease  the  pain  is  more 
continuous,  is  made  worse  by  eating,  and  is  often  associated 
with  local  tenderness  and  heematemesis. 

Cancer. — The  age,  history,  continuous  pain  which  is  in- 
creased by  eating,  hsematemesis,  tuMor,  cachexia,  anorexia, 
and  absence  of  hydrochloric  acid  will  separate  cancer  from 
gastralgia. 

Angina  Pectoris. — The  radiation  of  the  pain  from  the  heart 
down  the  arm,  fixation  of  the  body,  fear  of  impending  death, 
and  the  associated  symptoms  of  fatty  heart,  such  as  arcus 
senilis,  rigid  radials,  and  altered  heart-sounds,  will  separate 
angina  pectoris  from  gastralgia. 

The  lancinating  pains  of  locomotor  ataxia  sometimes  attack  s 
the  stomach  and  produce  what  are  termed  gastric  crises. 
These  can  be  distinguished  from  simple  gastralgia  by  the 
absence  of  the  patellar  reflex,  by  the  Argyll-Robertson  pupil, 
the  loss  of  coordination,  and  by  paroxysmal  pains  in  other 
parts  of  the  body. 

Prognosis. — Favorable,  but  duration  indefinite. 


40  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

Treatment.  AUach. — Hot  fomentations  shonld  be  ap- 
plied locally,  and  Hoffmann's  anodyne  (5ss),  chloroform  (gtt. 
x),  dilute  hydrocyanic  acid  (gtt.  ij  in  hot  water),  or  the  follow- 
ing mixture  may  be  given  internally  : — 

^  Spt.  vin.  gal. 

Tinct.  opii  campli.,  aa  f5ss  ; 
01.  caryoph.,  gtt.  x. — M. 
Sig. — A  teaspoonful  in  hot  water. 

In  severe  cases  morphia  will  be  required. 

TJie  Interval. — Correct  the  hygiene,  regulate  the  diet,  and 
enjoin  rest.  Travel  may  be  extremely  valuable.  Neuras- 
thenia may  require  the  "  rest-cure."  Tonics  are  often  indi- 
cated. AVhen  there  is  hyperacidity,  salicylate  of  bismuth,  car- 
bonate of  soda,  or  aromatic  spirits  of  ammonia,  after  meals,  may 
1)6  very  serviceable.  Arsenic,  strontium  bromide  (gr.  x— xv),  va- 
lerian, and  dilute  hydrocyanic  acid  are  remedies  of  great  value. 

]^   Sodii   arsenat.,   gr.  ss ; 

Ext.  cannabis  ind.,  gr.  iij.— M.    (DaCosta.) 
Ft.  in  pil.  No.  XX. 
Sig.— One,  three  times  daily. 

GASTRIC  ULCER. 

(Simple  Ulcer,  Perforating  Ulcer.) 

Definition. — An  ulcer  arising  without  obvious  exciting 
cause,  but  which  is  probably  due  to  the  digestive  action  of 
highly  acid  gastric  juice  on  a  part  of  the  stomach  whose  nutri- 
tion has  been  impaired  by  some  local  disturbance  of  the  cir- 
culation. 

Etiology. — Female  sex,  age  (between  the  fifteenth  and  the 
fortieth  year),  overwork  with  poor  food,  and  ansemia  are  the 
predisposing  causes. 

Pathology. — From  some  local  disturbance  of  the  circula- 
tion— injury,  hemorrhage,  thrombosis,  embolism,  or  spasm  of 
the  vessels — the  part  is  self-digested. 

The  ulcer  is  round  or  oval,  usually  situated  at  the  pylorus, 
on  the  posterior  wall,  near  the  lesser  curvature.  It  has  a 
punched-out  appearance,  is  conical  in  shape,  with  the  apex 
towards  the  peritoneum,  and  is  without  an  inflammatory  areola. 


GASTBIC   ULCEIi.  41 

The  floor  of  the  ulcer  is  usually  smooth,  and  may  be  formed 
by  any  one  of  the  coats  of  the  stomach.  A  series  of  ulcers  is 
not  uncommon,  so  that  more  than  one  may  be  detected. 

Symptoms. — The  general  symptoms  of  dyspepsia ;  loss  of 
flesh  and  strength ;  and  the  following  characteristic  symp- 
toms :  (1)  Severe  pain,  increased  by  eating ;  it  may  radiate  to 
the  back  ;  it  may  be  paroxysmal ;  it  may  be  worse  in  certain 
positions.  (2)  Local  tenderness.  (3)  Persistent  vomiting  after 
taking  food  ;  the  gastric  jiiice  is  unnaturally  acid.  (4)  Hemor- 
rhage is  common ;  it  varies  in  amount  from  a  trace  of  blood 
to  a  quart  or  more. 

In  some  cases  only  the  symptoms  of  dyspepsia  are  present, 
while  in  others  all  symptoms  may  be  absent,  and  in  the  latter 
hemorrhage  or  perforation  may  be  the  first  indication. 

Events. — (1)  Eesolution.  (2)  Death  from  exhaustion, 
hemorrhage,  perforation  and  peritonitis,  or  pyloric  obstruction 
from  cicatricial  contraction. 

Diagnosis.  Ckincer. — The  age  (after  forty),  history,  down- 
ward course,  short  duration,  extreme  cachexia,  often  out  of 
proportion  to  gastric  symptoms,  tumor,  absence  of  hydro- 
chloric acid  and  blood  less  in  amount  and  more  disintegrated. 

Gasfralgia. — -The  pain  usually  appears  when  the  stomach  is 
empty,  and  is  relieved  by  food  and  pressure ;  no  hemorrhage, 
no  local  tenderness ;  other  nervous  phenomena  are  commonly 
present. 

Chronic  Gastritis. — Hemorrhage  rare,  tenderness  diffuse, 
pain  less  marked,  vomiting  less  frec^uent  and  persistent,  gastric 
acidity  less  than  normal. 

Prognosis. — Guardedly  favorable ;  such  complications  as 
hemorrhage  or  perforation  may  occur  without  warning,  and 
relapses  from  new  ulcers  are  not  uncommon. 

Treatment. — Absolute  rest  in  bed  and  rectal  feeding. 

Later,  and  in  less  severe  cases  from  the  beginning,  pre- 
digested  milk,  milk  and  lime-water,  buttermilk,  broths,  soft- 
boiled  eggs  and  preparations  of  corn-starch  may  be  given  by 
the  mouth  at  regular  and  frequent  intervals.  This  restricted 
diet  should  be  continued  for  eight  or  ten  weeks,  and  the  return 
to  solid  food  should  be  quite  gradual.  The  more  complete  the 
rest  the  more  rapid  will  be  the  cure.     Lavage  is  contraindi- 


V 


42  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

cated,  but  tlie  stomach  may  be  cleaned  by  tlie  sipping  of  hot 
alkaline  water  in  the  morning  before  breakfast.  Internally, 
snbnitrate  of  bismuth  and  nitrate  of  silver  are  useful  remedies. 

I^  Argenti  nitratis,  gr.  v  ; 
Ext.  opiiygr.  iij. — M. 
Ft.  in  pil,  No.  XX. 
Sig. — One  pill  thrice  daily  half  au  hour  before  meals. 

Or, 

^  Bismuth,  subnitrat.,  .5vj-5J  ; 

Creosot.,  gtt.  x  ; 

Morphin.  sulph.,  gr.  i-ij. — M. 
Ft.  in  chart.  No.  xx. 
Sig. — One  powder  before  meals. 

Instead  of  morphine,  cocaine  (gr.  ^)  may  be  added  to  each 
powder. 

When  there  is  much  pain  counter-irritation  will  be  of  ser- 
vice. Hemorrhage  will  require  absolute  rest ;  morphine  (gr.  ^) 
and  fluid  extract  of  ergot  hypodermically ;  an  ice-bag  to  the 
stomach,  and  pellets  of  ice  and  tannic  acid  (gr.  v-x)  by  the 
mouth. 

GASTRIC  CANCER. 

Varieties. — (1)  Hard  cancer  (scirrhus).  (2)  Soft  cancer 
(encephaloid).     (3)  Epithelioma.     (4)  Colloid  cancer. 

Etiology. — Male  sex,  age  (after  forty),  heredity,  and  ulcer- 
ation of  the  stomach  are  predisposing  caAises. 

Pathology. — Cancer  of  the  stomach  is  usually  primary  ; 
other  organs  being  involved  secondarily.  The  scirrhous  form 
is  the  most  common.  As  the  pylorus  is  the  usual  seat,  gastric 
dilatation  is  a  natural  sequence. 

Symptoms. — The  general  symptoms  of  dyspepsia,  with  the 
following  characteristic  symptoms :  Continued  pain,  often 
tenderness ;  vomiting  of  partially-digested  food ;  absence  of 
free  hydrochloric  acid  in  the  gastric  juice,  and  the  presence  of 
lactic  acid  after  a  flour-soup  test-meal ;  hsematemesis,  the  loss 
being  usually  slight,  and  the  blood  so  altered  by  the  gastric 
juice  that  it  presents  a  "  coifee-grouud  "  appearance  ;  presence 
of  a  tumor ;  loss  of  flesh  and  strength ;  extreme  anaemia ; 
involvement  of  the  superficial  lymph  glands. 


DILATATION  OF   STOMACH.  43 

When  the  pylorus  is  involved,  symptoms  of  gastric  clila- 
tation  win_  bemadded.  These  are  :  Vomiting,  after  the  lapse 
of  several  hours  or  days,  of  large  quantities  of  fermented  ma- 
terial rich  in  sarcinre  ventriculi,  increased  area  of  gastric  tym- 
pany on  percussion,  and  a  reversed  peristaltic  wave  on  inspec- 
tion. 

Diagnosis. — ^The  differential  diagnosis  of  gastric  cancer 
from  ulcer,  gastralgia,  and  chronic  gastritis  has  already  been 
discussed. 

Prognosis. — Absolutely  fatal.  The  duration  is  from  six 
months  to  two  years. 

Treatment.  Palliative. — A  liquid  or  semi-liquid  diet. 
Rest.  Hydrochloric  acid  and  pepsin  are  often  required  to  as- 
sist digestion.  When  the  stomach  is  dilated  lavage  mav  give 
relief.  Pain  should  be  relieved  by  morphine.  The  other 
symptoms  will  reqilire— tlie  treatment  indicated  in  gastric  ca- 
tarrh. At  present,  operative  interference  could  scarcely  be 
recommended.  '""^ 

PYLORIC  OBSTRUCTION  ANY)  DILATATIOIV 
OF  THE  STOMACH. 

Etiology. — The  causes  of  jpyloric  obstruction :  (1)  Pyloric 
tumors,  usually  malignant,  (2)  Tumors  of  adjacent  viscera 
pressing  on  the  pylorus  or  duodenum.  (3)  Cicatrix  of  an 
ulcer.     (4)  Fibroid  thickening  from  chronic  catarrh. 

Pyloric  obstruction  increases  the  resistance  offered  to  the 
expulsion  of  food,  and  in  its  efforts  to  overcome  this,  the  stom- 
ach first  becomes  hypertrophied  and  then  dilated. 

Causes  of  Dilatation  of  the  Stomach  {Gastrectasis). — (1)  Py- 
loric obstruction.  (2)  Relaxation  of  the  walls  from  simple 
atony  or  catarrh.     (3)  Excessive  ingestion  of  food  or  drink. 

Symptoms. — The  general  symptoms  of  dyspepsia,  with  the 
following  characteristic  symptoms,  most  of  which  relate  to  the 
vomit :  Vomiting  occurs  long  after  eating,  sometimes  sev- 
eral hours  or  days ;  the  amount  is  often  excessive,  sometimes 
several  quarts ;  it  is  sour  and  fermented,  and  on  standing  sep- 
arates into  a  sediment  of  undigested  food  and  a  supernatant 


44  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

liquid,  which  is  turbid  and  frothy ;  the  ejected  material  is  rich 
in  torulse  and  sarcinse  ventriculi.  There  is  obstinate  constipa- 
tion. 

Fig.  1. 


a.  Sarcina  ventriculi.    6.  Toriila  cerevisise. 

Physical  Signs.  Inspedion. — Bulging  over  the  epigas- 
trium ;  in  thin  subjects  the  outline  of  the  stomach  may  be 
visible.     Sometimes  a  peristaltic  wave  is  detected. 

Palpation. — A  splashing  fremitus. 

Percussion. — Increased  area  of  gastric  tympany.  Artificial 
distention  of  the  stomach  with  carbonic-acid  gas,  evolved  by 
the  administration  of  bicarbonate  of  soda  and  tartaric  acid,  is 
rarely  necessary,  and  is  sometimes  harmful. 

Auscultation. — Splashing  sounds.  These  are  often  audible 
at  some  distance,  and  hence  are  a  frequent  source  of  annoy- 
ance to  the  patient. 

Mensuration. — ^Normally  an  oesophageal  sound  may  be  in- 
serted a  distance  of  60  ctin.  from  the  teeth  ;  in  dilatation  it 
may  be  inserted  65  or  70  ctm. 

Prognosis. — Depends  on  the  cause;  it  should  always  be 
guarded.  It  is  more  favorable  in  dilatation  without  obstruc- 
tion. In  cicatricial  contraction  operative  interference  has  given 
fair  results.  In  cancer  the  prognosis  is  absolutely  unfavor- 
able. 

Treatment. — The  diet  should  be  light  and  nutritious,  not 
bulky,  and  should  be  given  in  small  amounts  at  frequent  in- 
tervals. Lavage  practised  two  or  three  times  M^eekly  is  of 
great  value.     In  cancer  the  treatment  is  palliative.     In  fibroid 


CONSTIPATION.  45 

thickening  and  cicatricial  constriction,  dilatation  of  the  pylorus 
(Loreta's  operation)  or  the  establishment  of  a  gastro-duodenal 
fistula  may  be  suggested.  These  operations  have  been  fairly 
successful.  In  simple  dilatation,  treat  the  catarrh  and  apply 
massage  and  electricity ;  the  latter  may  be  applied  to  the  in- 
terior of  the  stomach  by  means  of  a  bij)olar  stomachal  elec- 
trode. (Rockwell.)  Tonics,  especially  strychnine,  are  often 
valuable  adjuncts.  An  abdominal  support  often  relieves  some 
of  the  distressing  symptoms. 

HJEMATEMESIS. 

(Gastrorrhagia. ) 

Etiology. — (1)  Traumatism.  (2)  Acute  gastritis.  (3) 
Obstruction  to  the  circulation,  as  in  chronic  heart,  lung,  and 
liver  disease.  (4)  Vicarious  menstruation.  (5)  Blood  dys- 
crasia,  as  in  scurvy,  infectious  fevers,  grave  ansemia,  purpura, 
etc.  (6)  Rupture  of  an  aneurism.  (7)  Gastric  ulcer.  (8) 
Gastric  cancer.  (9)  Swallowing  of  blood  from  nose,  mouth, 
or  throat,     (10)  Hysteria. 

Diagnosis.  Hmmatemesis. — Blood  is  often  clotted  and 
mixed  with  food,  is  acid  in  reaction;  the  subsequent  stools 
may  be  tarry,  and  the  associated  symptoms  usually  point  to 
the  stomach  or  adjacent  organs. 

Haemoptysis. — Blood  is  red,  frothy,  and  alkaline  in  reaction, 
the  subsequent  expectorations  are  streaked  with  blood,  and 
physical  signs  usually  indicate  the  cause. 

Treatment. — Absolute  rest ;  abstinence  from  food  by  the 
mouth  :  an  ice-bag  to  the  stomach.  Pellets  of  ice  may  be 
sucked.  Tannic  acid  (gr.  v-x)  by  the  mouth,  and  fluid  ex- 
tract of  ergot  (5ss)  with  morphia  (gr.  ^)  hypodermically.  If 
the  hemorrhage  has  been  profuse,  use  subcutaneous  injections 
of  weak  saline  solutions ;  give  iron  by  the  mouth,  and  advise 
the  use  of  salty  broths. 

CONSTIPATION. 

Definition. — An  unnatural  detention  of  fecal  matter. 
Etiology. — (1)  Many  acute  and  chronic  diseases  which 
lessen  peristalsis  and  secretion,  as  most  chronic  visceral  dis- 


46  DISEASES    OF   THE   DIGESTIVE   SYSTEM. 

eases,  nil  nervous  diseases,  anaemia,  and  the  infectious  fevers, 
except  typhoid.  (2)  Sedentary  habits.  (3)  Concentrated 
food.  (4)  Certain  drugs,  as  lead  and  opium  ;  it  is  an  after- 
eifect  of  strong  purgatives.  (5)  Atony  of  the  intestinal  wall, 
common  in  the  old  and  debilitated.     (6)  Stricture. 

Symptoms. — Infrequent  stools,  dyspepsia,  fetid  breath, 
headache,  vertigo,  lassitude,  aneemia. 

Results. — In  aggravated  cases  :  dyspepsia,  diarrhoea  from 
ii-ritation,  fecal  accumulation,  hemorrhoids,  fissure,  fistula, 
prolapse  of  the  rectum. 

Treatment. — A  regular  time  for  defecation  should  be  ob- 
served. Systematic  exercise,  abdominal  massage,  and  elec- 
tricity are  valuable  aids.  Encourage  the  use  of  water,  bran- 
bread,  green  vegetables,  and  stewed  fruits.  In  mild  cases  a 
glass  of  water  or  an  orange  before  breakfast  will  suffice.  Ene- 
mata  of  water,  or  glycerine  (3j-3iv),  or  suppositories  of  glyc- 
erine or  of  gluten  may  be  required. 

Mineral  waters,  like  Friedrichshall  or  Hunyadi,  often  give 
rehef. 

In  obstinate  cases  mild  laxatives  must  be  employed  ;  cascara 
sagrada  is  one  of  the  best.  The  dose  of  the  extract  is  one  to 
three  grains  ;   of  the  fluid  extract,  half  to  a  fluid  drachm. 

Sometimes  combinations  are  desirable. 

^  Aloiu,  gr.  iv  ; 

Styrchniupe,  gr.  ^  ; 

Ext.  belladonuse, 

Pulv.  ipecac,  aa  gr.ij.— M. 
Ft.  in  pil.  No.  sx. 
Sig. — One  or  two  as  required. 

Or, 

^  Pulv.  rhei,  gr.  xl ; 

Pulv.  aloes,  gr.  xx  ; 

Ext.  physostig.,  gr.  iij  ; 

01.  caryophylli,  gtt.  iij. — M 
Ft.  in  pil.  No.  XX. 
Sig. — One  or  two  as  required. 


DIAEEHCEA.       •  47 

INTESTINAX.  COLIC. 

(Enteralgia,  Tormina.) 

Definition. — A  painful  spasmodic  affection  of  the  intes- 
tines. 

Etiology. — It  usually  results  from  irritating  food,  flatu- 
lence, or  fecal  accumulation.  It  is  sometimes  of  rheumatic  or 
gouty  origin.  It  may  be  reflex  from  disease  of  the  ovaries, 
uterus,  liver,  spine,  etc.  It  is  also  a  symptom  of  lead-poison- 
ing, intestinal  inflammation,  and  intestinal  obstruction.  It  may 
be  a  crisis  of  locomotor  ataxia. 

Symptoms. — Paroxysms  of  severe  pain  of  a  twisting  char- 
acter, centering  around  the  umbilicus,  and  relieved  by  pressure. 
The  abdomen  is  usually  distended.  Severe  attacks  may  lead 
to  incipient  collapse,  indicated  by  cold  sweats,  pinched  features, 
feeble  pulse,  and  vomiting.  The  attack  lasts  from  a  few 
minutes  to  several  hours,  and  usually  ends  by  a  discharge  of 
flatus. 

Diagnosis.  Lead  Colic. — History,  blue  line  on  the  gums, 
retracted  abdominal  walls,  and  lead  in  the  urine. 

Biliary  Colic. — Pain  radiating  from  the  liver  to  the  back 
and  right  shoulder,  jaundice,  and  calculus  in  the  stool. 

Renal  Colic. — Pain  radiating  down  the  ureter  to  penis  and 
testicle,  blood,  mucus,  pus,  or  calculi,  in  the  urine. 

Abdominal  Aneurism. — Tumor,  pulsation,  bruit. 

Peogn  osis. — Favorable. 

Teeatment. — Apply  hot  applications  to  abdomen,  and 
administer  morph.  (gr.  ^)  with  sulphate  of  atropine  (gr.  jtU") 
hypodermically.  Subsequently  employ  a  saline  or  mercurial 
purge.     In  the  interval  treat  the  causal  condition. 

Lead  Colic. — Use  magnesium  sulphate  as  a  cathartic,  and 
potassium  iodide  (gr.  v-x,  thrice  daily)  to  eliminate  the  lead. 

'diabrh(ea. 

Definition. — A  condition  in  which  the  stools  are  too  fre- 
quent or  too  liquid.  Like  dyspepsia,  it  is  a  symptom  of  many 
pathological  conditions. 

Etiology. — (1)   It  results  from  inflammation  of  the  in- 


48  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

testines^  as  enteritis,  entero-colitis,  dysentery.  (Inflammatory 
diarrhcea.)  (2)  It  is  a  symptom  of  certain  infections  diseases, 
as  typhoid  fever,  cholera.  (Symptomatic  diarrho?a.)  (3)  It  is 
produced  by  certain  drugs,  as  laxatives  and  purgatives.  (4)  It 
may  be  an  expression  of  cachexia  occurring  as  a  final  symptom 
in  cancer,  diabetes,  and  chronic  Bright's  disease.  (Colliqua- 
tive diarrhoea.)  (5)  It  may  be  a  closing  symptom  in  acute 
febrile  diseases  which  end  by  crisis,  as  typhus  fever,  re- 
mittent fever.  (Critical  diarrhoea.)  6.  It  may  result  from 
nervous  excitement  or  sensational  disturbance.  This  is  prob- 
ably due  to  a  vaso-motor  paresis  of  the  intestinal  vessels  (an 
intestinal  "blush"),  and  the  subsequent  outpouring  of  serum. 
(Nervous  diarrhoea.) 

rNTESTEVAL.  CATABRH. 

(Diarrhoea,  Catarrhal  Enteritis.) 

Etiology. — Warm  weather,  childhood,  and  bad  hygiene 
are  general  predisposing  causes.  It  is  usually  excited  by  a 
sudden  change  in  temperature,  or  by  irritating  products  in  the 
intestinal  canal,  as  harsh  food,  ptomaines,  or  bacteria.  It  may 
be  induced  by  corrosive  poisons,  as  antimony,  arsenic,  mer- 
cury. 

Pathology. — The  mucous  membrane,  especially  of  the 
upper  bowel,  is  injected,  swollen,  and  covered  with  tenacious 
mucus.  The  solitary  and  agminated  glands  are  enlarged,  and 
are  sometimes  the  seat  of  pinhead  ulcerations. 

In  chronic  enteritis  the  mucous  membrane  is  often  thickened 
from  an  overgrowth  of  connective  tissue,  but  in  some  instances 
it  is  unusually  thin  from  atrophy  of  the  coats  and  destruction 
of  the  glands. 

Symptoms.  Acute  Enteritis. — Frequent  stools,  three  to 
twelve  or  more  a  day ;  they  are  usually  of  a  yellowish  or 
greenish  color,  and  frequently  contain  undigested  food. 
Colicky  pains,  and  rumbling  noises  (borborygmi),  coated 
tongue,  anorexia,  and  sometimes  slight  fever. 

Chronic  Enteritis. — Frequent  liquid  stools  which  vary  in 
jcolor  and  character  according  to  the  seat  of  catarrh ;   much 


INTESTINAL   CATAREH.  49 

undigested  food  (lienteiy)  indicates  involvement  of  the  upper 
bowel;  and  much  mucus,  involvement  of  the  lower  bowel. 
The  excessive  drain  leads  to  anaemia,  emaciation,  and  weak- 
ness. 

Membranous  Enteritis. — This  term  has  been  applied  to  two 
conditions  :  (1)  A  true  croupous  enteritis,  which  is  associated 
with  the  formation  of  a  false  membrane,  and  which  is  seen  in 
cachectic  states,  in  acute  infectious  diseases,  and  as  a  result  of 
mineral  poisoning.  (2)  Mucous  colic,  or  mucous  colitis,  a  ^ 
chronic  form  of  colitis,  usually  occurring  in  women  of  a 
marked  nervous  temperament,  and  characterized  by  paroxysms 
of  severe  pain,  and  the  discharge  of  gray  translucent  casts 
which,  however,  are  not  membranous,  but  mucoid  in  character. 

Diagnosis.  Dysentery. — Bloody  and  mucous  discharges, 
tenesmus,  greater  prostration. 

Entero- colitis. — Moderate  fever,  greater  prostration,  tender- 
ness along  the  colon ;  stools  contain  mucus,  blood,  and  ma- 
terial resembling  chopped  spinach. 

Prognosis. — Good,  under  favorable  conditions. 

Treatment. — In  adults. — Rest.  Liquid  diet.  When 
there  is  retention  of  irritating  material,  indicated  by  the  his- 
tory, sharp  pain,  abdominal  distention,  and  small  stools,  ad- 
minister a  laxative,  as  calomel,  or  castor  oil  with  laudanum. 

^  Hydrarg.  chlor.  mit.,  gr.  ij  ; 
Sodii  bicarb.,  3j. — M. 
Ft.  in  chart.  No.  xii. 
Sig. — One  every  hour  until  five  or  six  have  been  taken. 

Or— 

^  01.  ricini, 

Syr.  rhei  aromat.,  aa  f^ss  ; 
Tinct.  opii,  gtt.  x-xx. — M. 
Repeat,  if  necessary. 

When  the  bowel  has  been  thoroughly  emptied,  opiuni,  as- 
tringents, and  intestinal  antiseptics  will  be  required.     Thus  : — 

'^  Bismuth,  subnit.,  ^ss  ; 
Morphin.  sulph.,  gr.  j  ; 
Creosoti,  gtt.  vj. — M. 
rt.  iu  chart.  No.  xii. 
Sig. — One  every  two  hours. 
4 


50  DISEASES   OP   THE   DIGESTIVE  SYSTEM. 

Or— 

]^   Bismuth,  subnit., 
Cretie  prrepar.,  aa  ^ij  ; 
Tiuct.  opii  camph.,  i's'iss  ; 
Tiuct.  kiuo,  f^ij  ; 
Pulv.  acacia?,  q.s ; 

Aqua?  ciuDamomi,  q.s.  ad.  f5vj. — M. 
Sig, — A  tablespoonful  every  three  hours. 

Chronic  Diarrho'a. — Liquid  diet.  Rest.  Intestiual  antisep- 
tics (salicylate  of  bismuth,  naphtbaliu,  salol),  and  opium  with 
mineral  astringents. 

D'larrhcva  in  Children. — Absolute  cleanliness.  Frequent 
bathing.  A  change  of  air,  if  possible.  If  the  child  is  bottle- 
fed,  the  milk  must  be  sterilized  and  given  at  regular  intervals. 

If  the  diarrho?a  still  persists,  milk  should  be  abandoned,  and 
the  child  fed  for  a  few  days  on  egg  albumin,  beef  juice,  or 
beef  peptonoids.  A  flannel  binder  should  be  applied  to  the 
abdomen.  The  bowels  should  be  emptied  with  castor  oil  (3j) 
to  which  may  be  added  a  few  drops  of  paregoric ;  or — 

^  H3-drarg.  chlor.  mit.,  gr.  j  ; 

Bismuth,  salicylat.,  gr.  xxxyj  ; 

Pulv.  zingiber.,  gr.  xij. — M. 
Ft.  in  chart.  Xo.  xii. 
Sig. — One  every  hour. 

After  this  has  operated,  astringents  may  be  employed. 

^   Sodii  salicylat.,  gr.  xij  ; 

Bismuth,  subnit.,  gr.  xxxvi ; 

Pulv.  aromat.,  gr.  vj. — M. 
Ft.  in  chart.  I^o.  xii. 
Sig.— One  every  two  hours. 

^   Sodii  bicarb. ,  gss  ; 

Syr.  rhei  aromat.,  f|ss; 
Aq.  meuth.  pip.,  f5ijss.— M.    (Starr.) 
Sig. — 5j  every  two  hours. 

Or— 

K     Sodii  salicylat.,  gr.  xxiv; 
Bismuth,  subuit.,  3ij;___ 
Tinct.  opii  camph.,  t'oiij ; 
Mist,  cretae,  i'siss; 
Aqute  cinuamomi,  q.s.  ad  f^iij. — M. 
Sig. — One  to  two  teaspoonfuls  every  two  hours. 


ENTEEO-COLITIS.  51 

ACUTE  ENTERO-COLITIS. 

(Follicular  Enteritis.) 

Definition. — An  inflammation  involving  mainly  the 
ileum  and  colon,  and  affecting  especially  the  lymphatic  glands. 

Etiology. — Warm  weather,  childhood,  improper  food,  and 
bad  hygiene  are  predisposing  factors. 

It  usually  follows  catarrhal  enteritis  or  cholera  infantum. 

Pathology. — The  mucous  membrane  is  red,  swollen,  and 
(edematous.  The  solitary  and  agminated  glands  are  swollen 
and  often  ulcerated. 

Syimptoms. — Frequent  stools,  at  first  yellow,  later  green, 
and  mixed  with  curd,  mucus,  blood,  and  sometimes  material 
resembling  chopped  spinach.  The  dejecta  are  neutral  or  acid 
in  reaction.  There  is  moderate  fever  (101°-102°),  with  its 
usual  phenomena.  The  abdomen  is  distended,  and  tender 
along  the  colon.  Vomiting  is  rarely  persistent.  The  child 
grows  pale,  wastes,  and  assumes  a  senile  appearance.  Death 
may  be  preceded  by  coma  and  convulsions,  (Spurious  hydro- 
cephalus.) 

Diagnosis. — Reference  has  already  been  made  to  its  sepa- 
ration from  catarrhal  enteritis. 

Cholera  infantum  may  be  recognized  by  the  abrupt  onset, 
very  liigh  fever,  incessant  vomiting,  serous  purging,  and  early 
collapse. 

Prognosis. — Grave,  yet  recoveries  follow  under  favorable 
conditions. 

Treatment. — Much  the  same  as  in  catarrhal  enteritis. 
Stimulants  are  frequently  required.  Weak  stupes  or  spice 
poultices  should  be  applied  to  the  abdomen.  Topical  treat- 
ment should  not  be  neglected.  The  bowel  should  be  irrigated 
once  a  day  with  a  pint  or  more  of  tepid  water  containing  one 
per  cent,  of  benzoate  of  soda  or  salicylic  acid.  The  irrigation 
may  be  followed  by  the  injection  of  an  ounce  of  water  con- 
taining nitrate  of  silver  (gr.  -|-1)  and  perhaps  laudanum  (gtt. 

ij-iij)- 


52  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

DYSENTERY. 

(Bloody  riux.) 

Definition. — An  inflammatory  disease  of  the  colon,  char- 
acterized by  tenesmus,  and  the  passage  of  small,  mucous,  and 
blood-streaked  stools. 

Etiology. — (1)  Warm  climates  and  warm  weather;  (2) 
bad  hygience ;  (3)  ingestion  of  irritating  food  ;  (4)  exposure 
to  cokl  and  wet ;  (5)  cachectic  states  (scurvy,  gangrenous 
stomatitis,  aud  Bright's  disease)  are  predisposing  factors,  and 
alone  may  produce  simple  dysentery ;  but  the  tropical  form 
(also  occurs  in  cold  climates)  seems  to  be  excited  by  an  animal 
parasite,  the  amoeba  coli. 

The  disease  frequently  occurs  in  epidemic  form. 

Yaeieties. — (1)  Acute  catarrhal  or  sporadic  dysentery. 
(2)  Amoebic  or  tropical  dysentery.  (3)  Malignant  or  diph- 
theritic dysentery.     (4)  Chronic  dysentery. 

Pathology.  Catarrhal  Dysentery. — Mucous  membrane  of 
the  colon  is  red,  swollen,  oedematous,  and  in  some  cases  ulcer- 
ated. 

Fig.   2. 


Amceba  coli. 

Amoebic  Dysentery. — The  mucous  membrane  is  swollen  from 
oedema  and  cellular  infiltration.  The  latter  causes  superficial 
necrosis,  and  the  formation  of  irregular  ulcers  which  more  or 
less  undermine  the  surrounding  mucosa.  The  amoebae  are 
found  in  the  floor  of  the  ulcers,  and  in  the  surrounding  tissue. 
In  some  cases,  false  membrane  and  sloughs  appear.  Abscess 
of  the  liver  is  a  common  complication. 

Diphtheritic  Dysentery. — The  mucous  membrane  is  intensely 
swollen,  and  covered  with  a  false  membrane,  which  results 


DYSEXTERY.  53 

from  coagulation-necrosis.     The  separation  of  the  membrane 
is  followed  bv  ulceration  and  sloughing. 

Chronic  Dysentery. — May  be  simple  or  amcebic.  The  coats 
are  greatly  thickened  and  ulcers  are  usually  found.  Cicatri- 
cial contractions  sometimes  follow. 

Symptoms.  Acute  Catarrhal  Dysentery. — Moderate  fever 
and  its  associated  phenomena,  prostration,  colic,  abdominal 
tenderness,  tenesmus  (fulness  in  the  rectum  Avith  a  constant 
desire  to  defecate)  with  small,  mucous,  and  bloody  stools. 

Amcebic  Dysentery. — May  begin  as  an  acute  or  chronic  dis- 
ease. The  symptoms  are  similar  to  catarrhal  dysentery,  but 
the  disease  is  more  protracted,  and  often  marked  by  intermis- 
sions and  exacerbations ;  the  stools  are  more  fluid  and  contain^ 
the  amoeba  coli,  and  abscess  of  the  liver  is  a  more  frequent 
complication  than  in  other  forms  of  dysentery. 

JIalignant  or  Diphtheritic  Dysentery.  —  To  the  ordinary 
symptoms  the  following  typhoid  phenomena  are  added  :  Mut- 
tering delirium,  stupor,  subsultus,  carphologia,  and  a  brown, 
fissured  tongue.  The  stools  also  contain  false  membrane  and 
sloughs. 

Chronic  Dysentery. — Great  loss  of  flesh  and  strength ;  ex- 
treme aneemia;  the  discharges  contain  considerable  mucus 
and  at  times  are  bloody.  Tenesmus  and  pain  may  be  absent. 
The  history  of  the  initial  symptoms  will  establish  the  diagnosis. 

DiAGXOSis.  Diarrhcea. — Absence  of  tenesmus  and  of 
mucoid  and  bloody  stools. 

Intussusception. — Late  development  of  fever,  stools  more 
bloody  than  mucoid,  the  presence  of  a  '' sausage-like"  tumor 
and  persistent  vomiting. 

Prognosis. — In  acute  catarrhal  dysentery  the  prognosis  is 
good  ;  recovery  usually  follows  in  from  a  few  days  to  a  week. 
in  amcebic  dysentery  the  prognosis  should  be  guardedly 
favorable ;  relapses  are  common,  and  abscess  of  the  liver  is 
liable  to  occur.  The  duration  in  favorable  cases  is  from  six 
to  eiffht  weeks.  Malio-uant  dvsenterv  is  alwavs  a  o;rave  dis- 
ease  and  often  proves  fatal. 

Complications. — Peritonitis  from  extension  or  perforation, 
hepatic  abscess,  stricture,  and  paralysis  from  neuritis. 

Treatment.  Acute  Dysentery. — Absolute  rest  and  the  en- 
forced use  of  the  bed-pan.     Liquid  diet.     Apply  externally 


64  i)ISEASfi9  OF  THfi  DlGfiSTlVJE  BY^TfiM. 

hot  fomentations,  mustard-poultices  or  leeches.  A  mild  laxa- 
tive is  indicated  in  the  beginning  ;  sulphate  of  magnesium  (gij), 
or  castor-oil  and  laudanum  might  be  selected,  and  either  may 
be  repeated  until  the  effect  is  produced. 

Internally,  bismuth  is  a  valuable  remedy ;  salicylate  of  bis- 
muth (gr.  x)  or  subnitrate  of  bismuth  with  salol  or  creosote 
may  be  employed. 

^  Morphin.  sulph.,  gr.  j  ; 

Bismuth,  subnit.,  ^ij  ; 

Creosoti,  gtt.  vj. — M. 
Ft.  in  pulv.  No.  xii. 
Sig. — One  every  hour  or  two. 

Or, 

IJL   Salol,  3j  ; 

Bismuth,  subnit., 

Sodii  bicarb.,  aa  gr.  c. — M. 
In  twenty  capsules.  (Dujardin-Beaumetz.  ) 

Sig. — One  three  or  four  times  daily. 

Musser  recommends — 

^  Quininfe  sulph.,  gr.  xl ; 

Ext.  opii,  gr.  v  ; 

Mass.  liydrarg.,  gr.  x. — M. 
Ft.  in  pil.  No.  xx, 
Sig. — One  or  two  every  two  or  three  hours. 

In  some  cases,  particularly  in  those  associated  with  bilious 
symptoms,  ipecacuanha,  in  large  doses  (gr.  xx-xxx,  repeated 
every  three  or  four  hours),  is  very  serviceable.  To  prevent 
emesis,  twenty  drops  of  laudanum  should  be  given  half  an  hour 
before  the  administration  of  the  ipecacuanha.  Topical  treat- 
ment should  never  be  omitted.  In  mild  cases  opium  supposi- 
tories will  prove  very  beneficial ;  in  severe  cases  enemata  of 
thin  starch-water  with  laudanum  (gtt.  xx-xxx)  should  be 
substituted  for  the  suppositories.  H.  C  Wood  highly  recom- 
mends the  use  of  ice  suppositories,  one  every  two  to  five 
minutes  for  half  an  hour,  followed  by  suppositories  of  ergot 
and  iodoform  : — 

^  Ext.  ergot.,  gr.  Ixxij  ; 

Iodoform. ,  ^ss  ; 

01.  theobrom.,  q.  s.— M. 
Ft.  in  suppos.  No.  vi. 
Sig. — One  every  two  hours  until  four  or  five  have  been  taken. 


CHOLERA  MORBUS.  BS 

Astringent  injections  of  nitrate  of  silver  or  lead  acetate  should 
be  reserved  for  subacute  or  chronic  cases. 

Injections  of  warm  solutions  of  quinine  (5oV¥  ^'^  r^Vo)  hS'Ve 
recently  been  employed  in  amoebic  dysentery  with  advantage. 
(Osier.)  Creolin  (a  drachm  to  the  pint)  has  given  good  results 
in  similar  cases. 

In  malignant  dysentery,  quinine,  alcohol,  and  turpentine 
are  indicated. 

Chronic  Dysentery. — Rest ;  liquid  diet ;  intestinal  antisep- 
tics (salicylate  of  bismuth),  and  copious  injections  of  nitrate  of 
silver  in  aqueous  solution,  as  recommended  by  Wood.  Begin 
with  one  or  two  pints  (gr.  xx  to  the  pint),  and  inject  through 
a  tube  pushed  far  up  the  bowel ;  later,  increase  to  three  or 
four  pints  (gr.  xxx  to  the  pint).  The  injections  may  be  em- 
ployed once  or  twice  weekly. 

CHOLERA  MORBUS. 

(English    Cholera,  Cholera  Nostras.) 

Definition. — An  acute,  sporadic  disease,  resembling  Asiatic 
cholera,  but  not  excited  by  the  comma  bacillus  of  Koch. 

Etiology. — The  summer  season  predisposes,  and  irritating 
food,  as  unripe  fruit,  and  a  sudden  change  of  temperature  are 
the  usual  exciting  causes.  A  ptomaine  or  a  special  bacillus 
probably  induces  the  disease. 

Symptoms. — Intense  cramps  in  the  stomach,  vomiting  and 
purging  of  bilious  material,  moderate  fever,  and  great  pros- 
tration. In  severe  cases  the  discharges  become  serous,  and 
symptoms  of  collapse  develop. 

Diagnosis.  Asiatic  Cholera, — The  presence  of  an  epidemic ; 
not  bilious,  but  rice-water  discharges  ;  the  detection  of  Koch's 
comma  bacillus. 

Corrosive  Poisons  (as  antimony). — History ;  the  vomiting 
precedes  purging ;  burning  pain  in  oesophagus  and  rectum ; 
and  bloody  mucous  discharges. 

Prognosis. — Favorable ;  death  rarely  occurs.  Duration, 
twenty-four  to  forty-eight  hours. 

Treatment. — Hot  applications  to  the  abdomen.  Morphine 
(gr.  I)  with  atropine  (gr.  xio)'  hypodermical-ly,  repeated  if 


56  DISEASES   OF  THE  DIGESTIVE   SYSTEM. 

necessary.  When  the  pain  is  less  severe  opium  may  be  given 
by  the  mouth  or  rectum.  Ice  is  soothing  and  relieves  the 
thirst.  When  vomiting  is  the  most  troublesome  symptom  the 
following;  will  be  beneficial : — 

]^  Morph.  sulph.,  gr.  j  ; 

Creosoti,  gtt.  vj  ; 

Bismuth,  subnit.,  gij.— M. 
Ft.  in  chart.  No.  xii. 
Sig. — One  every  hour. 

Prostration  will  require  stimulants,  like  aromatic  spirits  of 
ammonia  or  brandy. 

In  many  cases  the  following  mixture  will  be  all  that  is 
required  : — 

^   Tinct.  opii  caniph.,  f  §ss  ; 
Spt.  amnion,  aromat.,  f^j  ; 
Magnesife,  3j ; 
Aq.  menth.  piperitse,  q.  s.  ad.  f.^iv. — M. 

(Hartshorne.  ) 
Sig. — A  teaspoonful  every  twenty  minutes. 

CHOLERA  INFAIVTUM. 

Definition. — An  acute  disease  of  childhood,  characterized 
by  high  fever,  vomiting,  purging,  and  collapse,  and  dependent 
upon  an  inflammation  of  the  gastro-intestinal  tract,  and  some 
disturbance  of  the  sympathetic  ganglia. 

Etiology.- — Hot  weather,  faulty  feeding,  dentition,  and  bad 
hygiene  are  predisposing  factors. 

Pathology. — The  mucous  membrane  of  the  stomach  and 
intestines  is  red,  swollen,  and  cedematous  ;  the  glands  are  en- 
larged or  ulcerated.  The  profuse  serous  discharges  and  rapid 
collapse  must  be  due,  in  part,  to  some  disturbance  of  the  sym- 
pathetic nerves. 

Symptoms. — The  onset  may  be  gradual  or  abrupt.  Diar- 
rhoea is  usually  the  initial  symptom  ;  the  stools  are  thin  and 
serous,  have  a  musty  odor  and  an  alkaline  reaction.  Vomit- 
ing soon  develops,  aud  the  gastric  irritability  is  so  great  that 
everything  is  rejected.  Thirst  is  intense,  the  temperature  is 
very  high  (105°  to  108°);  the  pulse  is  rapid  and  feeble;  the 
urine  is  scanty.     Collapse  follows,  and   is  indicated  by  the 


CHOLERA   INFANTUM.  57 

pinched  features,  hollow  eyes,  sunken  fontanelles,  and  cold 
surface.  Even  at  this  time  a  reaction  may  set  in,  but  more 
commonly  death  results  from  exhaustion.  The  end  may  be 
characterized  by  the  symptoms  of  spurious  hydrocephalus — 
restlessness,  convulsions,  irregular  pupils,  and  coma ;  and  as 
these  phenomena  are  unassociated  with  any  cerebral  lesion 
they  are  probably  toxsemic. 

Diagnosis.  Enter o-colitis. — Gradual  onset,  moderate  fever, 
vomiting  less  marked,  stools  more  mucous  than  serous  and 
neutral  or  acid  in  reaction,  pulse  not  so  rapid,  and  no  tendency 
to  sudden  collapse. 

Prognosis.  —  Grave.  Under  conditions  most  propitious, 
death  may  result  in  from  one  to  three  days;  on  the  other 
hand,  no  aspect  is  too  serious  to  admit  of  recovery.  Entero- 
colitis is  a  common  sequel. 

Treatment. — If  possible,  the  child  should  be  removed  to 
the  country  or  seashore.  It  should  be  kept  in  the  open  air. 
Cleanliness  is  essential  to  success,  and  frequent  bathing  with 
cool  water  is  desirable.  A  spice-plaster  or  a  weak  stupe  should 
be  applied  to  the  abdomen. 

The  nourishment  should  consist  of  barley-water,  beef-juice, 
wine-whey,  chicken-broth,  or  frozen  blocks  of  beef-tea ;  these 
should  be  given  in  small  quantities  at  frequent  intervals. 
Pellets  of  ice  should  be  given  to  allay  thirst.  A  few  drops  of 
brandy  or  of  aromatic  spirits  of  ammonia  may  be  required  at 
frequent  intervals  to  combat  prostration. 

To  arrest  vomiting  use  calomel  (gr.  ■^■^),  subnitrate  of  bismuth 
(gr.  iij-v),  or  nitrate  of  silver, 

^   Argenti  nitrat.,  gr.  ss-j  ; 
Syr.  acacise,  f^  j  ; 
Aquae,  f|ij. — M, 
Sig. — A  teaspoonful  every  two  hours. 

For  the  diarrhoea,  laudanum  (gtt.  ij-iij)  with  starch-water 
(5j)  may  be  given  every  three  or  four  hours  by  the  rectum. 
Or  the  following  may  be  given  by  the  mouth  : — 

^   Liquor,  morph.  sulph.,    f^j  ; 
Acid,  sulphur,  aromat.,  tfl  xxiv  ; 
Elix.  curacofe,    f,^ss  ; 
Aqufe,  q.  s.  ad.  f^iij. — M. 
Sig,_One  teaspoonful  every  two  hours  for  a  child  six  months  old. 


/ 


58  DISEASES  Oi'  THE  DIGESTIVE  SYSTE^t. 

When  vomiting  and  purging  seem  uncontrollable,  morphine 
fe^*'  T2T  ^^  1  ot)  hypodermically  may  be  very  useful. 

Irrigation  of  the  stomach  and  bowel  with  warm  water  has 
been  highly  recommended,  and  though  heroic  sometimes  gives 
brilliant  results.  In  collapse,  use  a  hot  bath  to  which  a  little 
mustard  or  red  pepper  has  been  added  ;  then  place  the  child 
in  a  horizontal  position,  cover  with  warm  blankets,  and  ad- 
minister stimulants  freely. 

TYPHLITIS  AISD  APPENDICITIS. 

Definition. — Inflammatory  affections  of  the  right  iliac 
fossa  have  been  divided  into  :  (1)  Typhlitis,  an  inflammation 
of  the  caecum.  (2)  Appendicitis,  an  inflammation  of  the  ap- 
pendix. (3)  Perityphlitis,  an  inflammation  of  the  serous 
covering  of  the  ceecum. 

Etiology. —  Typhlitis,  or  Ccecitis,  is  an  uncommon  disease, 
and  usually  results  from  traumatism  or  fecal  impaction  (Typh- 
litis stercoralis).  Clinically  it  cannot  be  distinguished  from 
apnendicitis. 

y'jijppendicitis  is  a  common  affection.     Earlylife,  male  sex, 
^^  intestinal  catarrh,  ingestion  of  irritating  fooclTconstipation, 
''       and  previous  attacks  are  predisposing  factors.     Foreign  bodies 
or  fecal  accumulations  in  the  appendix  or  traumatism  usually 
excite  it.     It  may  be  due  to  tubercular  or  typhoid  ulceration. 
Perityphlitis  is  always  secondary  to  appendicitis. 
Pathology. — In  grave  cases  the  appendix  is  thickened, 
injected,  ulcerated,  or  necrosed ;    and  peritonitis  or  localized 
abscesses  are  frequently  discovered. 

^  Symptoms. — It  may    begin   gradually  or  abruptly.     The 

usual  manifestations  are  moderate  fever  (101°-104°)  with  its 

V  *^  associated  ^jhenomena ;   severe  pain  in  the  right  iliac  fossa, 

'  which  is  increased  by  flexing  and  extending  the  thigh  ;  consti- 

'    ,     pation,  and,  later,  vomiting. 

■^         Physical  Signs. — ^The  patient  usually  lies  with  the   right 
y       thigh  flexed. 

Palpation  elicits  tenderness,  and  sometimes  diffuse  or  cir- 
cumscribed induration.      When   the  appendix   is   favorably 


iNTESTlxVAL  OBS^J^tJCTlOIf.  59 

Situated,  a  finger  in  the  rectum  may  detect  fulness  and  indu- 
ration to  the  right. 

Percussion  often  yields  a  dull  note. 

In  some  instances  the  first  manifestation  is  general  peri- 
tonitis. It  should  be  borne  in  mind  that  abrupt  general 
peritonitis  without  obvious  cause  is  usually  due  to  appendicitis. 

Complications. — (1)  Peritonitis  by  extension  or  perfora- 
tion, (2)  Abscess,  pointing  externally  in  the  ileo-csecal  region, 
in  the  flank  or  buttock ;  or  internally,  exciting  peritonitis. 

Prognosis. — Always  guarded  ;  cases  apparently  mild  may 
terminate  fatally.  Mild  cases,  in  which  the  symptoms  are 
probably  due  to  typhlitis,  often  recover  rapidly  under  appro- 
priate treatment. 

Treatment.  —  Absolute  rest.  Liquid  diet.  The  lower 
bowel  should  be  emptied  by  enemata.  Opium  should  be  given 
for  the  relief  of  pain.  In  the  initial  stage,  salines  cautiously 
administered  may  yield  excellent  results ;  Epsom  salts  (3ij) 
should  be  given  every  two  hours  until  two  or  three  watery 
stools  have  been  produced. 

Local  Treatment. — An  ice-bag  may  be  placed  on  the  ileo- 
cecal region,  but  if  there  is  much  tenderness  leeches  followed 
by  poultices  give  the  most  relief. 

Increasino;  tenderness  and  induration,  a  stable  or  rising;  tern- 
perature,  persistent  vomiting,  obstinate  constipation,  or  increas- 
ing abdominal  tympany  will  each  demand  surgical  interference. 

Patients  subject  to  recurrent  attacks  should  be  scrupulously 
careful  as  regards  hygiene  and  diet ;  they  should  be  habitually 
clothed  in  flannel,  and  should  wear  an  abdominal  protector. 
Residence  in  a  dry  and  equable  climate  sometimes  secures  im- 
munity. A  formal  operation  for  the  removal  of  the  appendix 
should  be  considered  in  these  cases. 

rmCESTINAL  0BSTRUCTI0:N^  ;    ILEUS. 

Etiology.     Acute  Obstruction. — (1)  Congenital  occlusion. ^ 
(2)  Intussusception  (Invagination).    (3)  Strangulation,  internal 
or  external.     ('4)  Twists  (Volvulus)  or  Knots. 

The  following  are  conditions  which  produce  chronie  obshnie- 
tion,  though  at  times  the  symptoms  develop  acutely  :  (1)  Stric- 


60  DISEASES  OE  THE   DIGESTIVE  SYSTEM. 

ture  from  a  healed  ulcer.  (2)  Unnatural  accumulations,  as 
fecal  masses  (Coprostasis),  foreign  bodies,  gall-stones.  (3) 
Tumors,  within  or  without. 

Symptoms.  Acute  Obstruction. — (1)  Sudden  pain,  at  first 
paroxysmal,  but  later  continuous.  (2)  Constipation.  (3) 
Vomiting,  persistent,  and  becoming  fecal  (stercoraceous). 
(4)  Abdominal  distention.  (5)  Collapse,  indicated  by  pinched 
features,  cold  extremities,  and  feeble  pulse. 

Chronic  Obstruction. — These  symptoms  devolop  slowly. 
\     Congenital  Occlusion. — The  usual  location  is  the  anus   or 
rectum.     It  is  detected  by  direct  examination. 

Intussusception. — The  slipping  of  a  portion  of  intestine  into 
another  portion  immediately  below  it.  It  is  noted  chiefly  in 
children,  and  is  more  common  in  males.  Its  exciting  cause  is 
probably  perverted  peristalsis,  whereby  one  part  of  the  bowel 
is  contracted  while  the  adjacent  part  is  dilated.  In  rare  in- 
stances it  has  been  induced  by  the  traction  of  intestinal  polypi. 
The  usual  seat  is  the  ileo-csecal  region. 

Multiple  invaginations  are  frequently  found  post-mortem, 
which  have  resulted  from  the  irregular  peristalsis  occurring 
just  before  death  ;  they  possess  no  inflammatory  characteris- 
tics. In  invaginations  not  cadaveric,  the  parts  are  injected, 
swollen,  and  covered  with  lymph. 

Diagnosis. — The  symptoms  of  obstruction,  with  the  age; 
a  "sausage-shaped"  tumor  in  the  line  of  the  colon  ;  the  rare 
detection  of  the  invaginated  portion  in  the  rectum  ;  tenesmus; 
^  and  bloody  mucous  stools  are  the  diagnostic  features. 

Peognosis  . —  Death  usually  results  from  gangrene,  peri- 
tonitis, or  collapse.  A  favorable  termination  sometimes  results 
from  the  escajDe  of  the  incarcerated  part,  or  by  a  sloughing  oif 
of  the  strangulated  portion  and  adhesion  of  the  serous  surfaces. 

Strangulation. — This  often  occurs  in  external  hernia,  when 
it  can  be  recognized  by  an  examination  of  the  inguinal, 
femoral,  and  umbilical  rings. 

Internal  Strangulation  is  due  to  the  slipping  of  a  coil  of 
intestine  through  the  diaphragm,  foramen  of  Winslow,  an 
abnormal  opening  in  the  omentum  or  mesentery,  or  a  loop  of 
inflammatory  lymph. 


INTESTINAL   OBSTRUCTION.  61 

Diagnosis. — It  might  be  suspected  by  the  absence  of  other 
cause,  by  the  sudden  onset,  or  by  a  history  of  previous 
peritonitis. 

Twist. — Occurs  most  commonly  in  middle-aged  men.  The 
usual  seat  is  the  sigmoid  flexure.  A  relaxed  and  lengthened 
mesentery  is  a  predisposing  factor. 

Diagnosis. — Rarely  possible. 

Stricture. — Usually  results  from  syphilitic,  tuberculous,  or 
dysenteric  ulcers.     The  rectum  is  the  most  common  seat. 

Diagnosis.  —  History,  gradual  onset,  results  of  rectal 
examination,  and  "pipe-stem"  or  "ribbon-like"  stools  are 
diagnostic  features. 

Unnatural  Accumulations. — Fecal  impaction  is  recognized 
by  the  gradual  onset,  mild  obstructive  symptoms,  history  of 
constipation,  and  a  painless,  irregular,  doughy  tumor  in  the 
line  of  the  colon. 

Gall-stones  may  obstruct  tlie  ileum ;  the  history  will  aid  in 
their  recognition. 

Tumors. — The  most  common  tumor  within  the  bowel  is  a 
cancer ;   it  is  usually  located  in  the  sigmoid  flexure  or  rectum. 

Diagnosis. — Age,  gradual  onset,  pain,  bloody  discharges, 
cachexia,  and  a  tumor  in  the  rectum  are  the  characteristic 
features. 

Tumors  of  adjacent  viscera  may  compress  the  bowel.  Their 
recognition  will  depend  upon  physical  examination. 

Treatment. — In  all  cases  of  acute  obstruction,  excepting 
external  hernia  and  congenital  atresia,  whether  the  cause  is 
apparent  or  not,  observe  the  following  rules  : — 

1.  Administer  opium  to  relieve  pain  and  check  peristalsis. 

2.  Apply  hot  fomentations  to  the  abdomen. 

3.  Restrict  the  diet  to  liquids  in  small  quantities.  Nutri- 
tive enemata  should  be  employed  in  the  weak, 

4.  Avoid  purgatives. 

5.  Elevate  the  buttocks,  insert  a  rectal  tulje,  and  distend 
the  colon  with  from  two  to  six  quarts  of  tepid  water,  which 
should  flow  from  a  reservoir  placed  from  ten  to  twenty  feet 
above  the  patient.  The  age  will  determine  the  length  of  the 
tube  and  the  amount  of  fluid. 

6.  When  the  stomach  and  upper  bowel  are  distended  by 


62  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

gas,  washiug  out  of  the  stomach  is  useful.  (Kiissmaul,  Lieber- 
Daeister.) 

7.  After  failure  iu  these  methods  laparotomy  should  not 
be  delayed  ;  the  earlier  its  performance  the  greater  the  chance 
of  success. 

In  fecal  impaction  administer  salines  and  inject  water  or  oil. 
Electricity  is  sometimes  useful.  Rectal  accumulations  may  be 
removed  by  the  fingers  or  a  suitable  scoop. 

Strictures  require  surgical  interference. 

ANIMAL.  PAKASITIC  APFECTIONS. 

Tape-worms. 

Varieties.  —  Taenia  solium.  Taenia  saginata.  Bothrio- 
cephalus  latus.     Taenia  echinococcus. 

History. — The  eggs  of  the  tape-worm  are  ingested  by  an 
animal,  and  embryos,  or  proscolices,  are  liberated  in  the 
stomach ;  these  migrate  to  other  organs,  where  they  are 
transformed  into  larvae  or  scolices.  The  encysted  larva,  or 
scolex,  is  termed  a  cysticercus ;  the  condition  is  known  as 
"  measles."  The  mature  worm  develops  in  man  from  the 
cysticercus  contained  in  infected  meat. 

Taenia  Solium  {Porh  Tape-worm). — Is  derived  from  the  hog, 
and  is  two  or  three  yards  in  length.  The  head  is  the  size  of 
that  of  a  pin,  is  provided  with  four  pigmented  cup-like 
suckers,  surrounded  by  a  double  row  of  booklets,  and  is 
attached  to  the  body  by  a  thread-like  neck.  The  sexual  ori- 
fice is  in  the  centre  of  the  broad  surface  of  the  segment. 

TaBuia  Saginata  (Tcenia  Mediocanellata). — Is  derived  from 
beef,  and  is  five  or  six  yards  in  length.  The  head  is  larger 
than  that  of  the  taenia  solium,  and  has  four  large  suckers,  but 
no  booklets.  The  segments  are  fatter,  and  the  uterine 
branches  are  finer  and  more  numerous  than  in  the  taenia 
solium.  * 

Bothriocephalus  Latus. — Is  found  especially  in  Europe, 
and  is  derived  from  fish.  The  head  has  no  booklets,  but  two 
lateral  grooves.  The  body  is  very  long.  The  sexual  orifice 
is  on  the  narrow  side  of  the  segment. 


ANIMAL    PARASITIC   AFFECTIONS.  63 

Symptoms. — Often  absent.  Frequently  there  are  dyspeptic 
symptoms,  colicky  pains,  loss  of  flesh,  capricious  appetite,  and 
sometimes  reflex  nervous  phenomena,  such  as  vertigo,  palpi- 
tation, "  night-terrors,"  convulsions,  itching  in  the  nose,  and 
choreic  movements. 

The  Diagnosis  rests  on  the  discovery  of  the  eggs  or  seg- 
ments in  the  stools. 

Treatment. — A  light  diet  for  a  day  or  two,  and  a  saline 
purge  prior  to  the  administration  of  the  anthelmintic.  After 
an  unsubstantial  breakfast  administer  one  of  the  following 
efficient  remedies  :  Pumpkin  seeds  (two  to  three  ounces) ;  oleo- 
resin  of  male  fern  (3j-ij))  pelletieriue,  the  alkaloid  of  pome- 
granate (gr.  v) ;  Kooso  (^ss). 

^   Oleoresin.  aspidii,  f3J  ; 

Pulv.  acacise  et  saccliar.,  aa  q.  s. 
Aquse  cinnamomi,  q.  s.  ad  f^ij. — M. 
Sig.— One  tablespoonful,  repeated  if  required. 

A  purge  should  be  given  a  few  hours  after  the  vermifuge. 
The  treatment  is  successful  only  when  the  head  is  passed. 

IVematocles. 

Ascaris  Lumbricoides  (Bound  Worms). — Life  history  un- 
known. They  are  of  a  pale-pink  color,  and  in  form  resemble 
earth-worms.  They  inhabit  the  small  intestines,  but  occa- 
sionally migrate  into  other  organs,  viz.,  stomach,  bile-ducts, 
and  larynx.     They  are  most  commonly  found  in  children. 

Symptoms. — Often  absent.  Sometimes  there  are  dyspepsia, 
mucous  stools,  colicky  pains,  voracious  appetite,  anaemia,  and 
reflex  nervous  phenomena,  as  "night-terrors,"  grinding.of  the 
teeth,  pruritus  of  nose  and  anus,  choreic  movements,  and  con- 
vulsions. 

Treatment — Santonin  (gr.  5-gr.  iij) ;  worm-seed  oil  (gtt.  x 
in  capsule  or  on  sugar) ;  fluid  extract  of  spigelia  (f 5j-f5iij)j 
are  efficient  remedies. 

^  Santonini,  gr.  vj  ; 

Hydrarg.  chlor.  mit.,  gr.  vj  ; 

Sacchari.,  gr.  xxiv  ; 
M,  et  ft.  chart.  ISTo.  xij.     (Stake.) 
Sig. — One  powder  morning  and  evening. 


64  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

Oxyuris  Vermicularis  {8eat-ivorm,  Fin-ivorm). — This  is  a 
small  worm,  most  commonly  seen  in  children,  and  occupies 
the  colon  and  rectum.  It  produces  intense  itching  of  the 
anus,  which  is  worse  at  night.  It .  may  migrate  into  the 
vagina  and  excite  pruritus  or  vaginitis,  and  lead  to  mastur- 
bation. 

Treatment. — An  injection  of  water,  followed  by  the  in- 
jection of  two  or  three  ounces  of  an  infusion  of  quassia  chips 
(5ij-iij  to  the  pint). 

Anchylostomum  Duodenale. — A  small  worm,  not  uncom- 
mon in  the  north  of  Europe  and  Egypt.  It  has  been  detected 
most  frequently  in  miners  and  brickmakers,  who  are  probably 
infected  by  drinking  water  containing  the  eggs  of  the  parasite. 
The  worm  inhabits  the  small  intestine. 

Symptoms. — Dyspepsia  and  intense  anaemia.  The  latter 
has  been  termed  Egyptian  chlorosis,  and  may  be  recognized  by 
the  detection  of  eggs  in  the  stools. 

Treatment. — Santonin,  male  fern,  and  thymol  have  been 
recommended. 

Tricocephalus  Dispar  (  WMp-worm). — A  small  worm,  thick 
at  one  end  and  thread-like  at  the  other.  It  occupies  the  colon 
and  csecum,  and  produces  but^ little  disturbance. 

Filada  Sanguinis  HominiS.  —  A  small  thread-like  worm, 
most  commonly  seen  in  the  tropics.  The  adult  occupies  the 
lymphatics,  and  the  female  brings  forth  a  great  number  of 
embryos,  which  soon  find  their  way  into  the  blood-current. 
The  embryos. of  the  most  important  species  of  filaria  (Filaria 
Bancrofti)  are  found  in  the  blood  only  at  night.  -  The  medium 
of  infection  is  probably  the  mosquito,  which  carries  the  embryo 
from  the  blood  to  the  water. 

Symptoms.  —  Often  absent.  Chyluria,  hsematuria,  and 
lymph-scrotum  sometimes  result  from  lymphatic  obstruction. 

Trichina  Spiralis. — A  small  worm  derived  from  the  hog. 
Man  is  infected  by  eating  insufficiently-cooked  pork  contain- 
ing the  encapsulated  worm.  The  worm  is  set  free  in  the 
stomach,  where  it  develops  and  brings  forth  living  embryos. 
These  soon  migrate  into  the  muscles,  where  they  in  turn  de- 
velop, coil  themselves  up,  and  become  encapsulated.  Trich- 
inous  capsules,  impregnated  with   lime-salts,  are   visible  to 


PERITONITIS.  65 

the  naked  eye,  and  are  sometimes  detected  accidentally  at 
autopsies. 

Symptoms  op  Trichinosis. — Sometimes  absent.  When 
large  numbers  have  been  ingested,  gastro-intestinal  symptoms 
develop  in  a  few  days.  These  are :  Pain,  nausea,  vomiting, 
and  serous  diarrhoea. 

Muscular  Symptoms. — In  from  one  to  two  weeks  muscular 
symptoms  develop.  The  muscles  become  swollen,  firm,  ex- 
tremely tender  and  painful.  Movement  is  inhibited,  and 
dyspnoea  results  from  the  involvement  of  respiratory  muscles. 
(Edema,  especially  of  the  face,  is  a  prominent  symptom.  Pro- 
fuse sweating  is  sometimes  observed,  and  high  fever  is  com- 
monly present. 

Prognosis. — Depends  on  the  number  of  worms  ingested. 
The  majority  of  patients  recover. 

Treatment. — Prevent  by  thoroughly  cooking  all  pork 
products.  In  the  first  stage  use  purgatives.  After  migration 
employ  opium,  warm  fomentations,  and  stimulants. 

PERITONITIS. 

Definition. — Inflammation  of  the  peritoneum. 

Varieties. — Accoi'ding  to   cause,  it  may  be  primary  or 
secondary  °  according  to  extent,  local  or  general ;  according  to 
time,  acute  or  chronic;   and  according  to  the  exudate,  sero-^^j^>^ 
fibrinous,  fibrinous,  or  purulent.  \^^^^'{^^^  . 

Etiology.  —  Acute   peritonitis   may   be:    (1)  Idiopathic,       jj 
arising  from  exposure  to  cold  and  wet  (rare).     (2)  Traumatic. ^'^'^^ 
(3)  Perforative,   resulting  from  a  perforating  wound,  or  the'^ 
rupture  of  a  gastric,  typhlitic,  typhoid,  or  dysenteric  ulcer,  or 
a  visceral  abscess.     (4)  Secondary  to  inflammatory  disease  of 
adjacent  viscera,  as  septic  endometritis  and   typhoid  fever. 
(5)  Secondary  to  some  general  morbid  process,  as  rheumatism, 
Bright's  disease,  scarlatina,  tuberculosis,  or  variola. 

Pathology. — In  the  first  stage  the  membrane  is  red, 
sticky,  and  histreless ;  later,  a  sero-fibrinous,  fibrinous,  or  puru- 
lent exudate  is  formed.  In  some  cases  the  exudate  is  tinged 
with  blood.  ^         ?/.-"=> 


66  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Symptoms.  Acute  General  Peritonitis. — Chill ;  moderate 
fever  (102°-103°),  with  its  associated  phenomena;  a  rapid, 
wiry  pulse ;  abdominal  pain  and  tenderness  so  intense  that 
abdominal  respiration  and  body  movements  are  inhibited  ;  the 
patient  lies  on  his  back  with  his  thighs  flexed  ;  the  features 
are  pinched;  the  vomiting  is  persistent;  the  bowels  are  usually 
V  constipated.    Hiccough  is  a  common  and  troublesome  symptom. 

Inspection  reveals  great  abdominal  distention. 

Palpation  elicits  tenderness,  and  rarely  a  friction  fremitus. 

Percussion  at  first  yields  universal  tympany ;  but  later, 
dulness  in  the  flanks  from  the  gravitation  of  the  exudate. 

Diagnosis.  Acute  Enteritis. — Pain  and  tenderness  not  so 
marked,  absence  of  wiry  pulse,  and  diarrhoea  instead  of  con- 
stipation. 

-.  Intestinal  Ohstrvbction. — Unless  associated  with  peritonitis, 
there  is  no  fever,  no  wiry  pulse,  nor  extreme  tenderness ;  the 
vomiting,  becomes  fecal. 

Hysterical  Abdomen. — This  condition  may  resemble  peri- 
tonitis in  all  particulars.  The  sex  and  personal  history  must 
be  considered.  Fever  is  not  usually  present,  the  pulse  is  not 
rapid  and  wiry ;  when  the  attention  is  distracted  the  pain  may 
vanish. 

Peognosis. — Generally  unfavorable.  Death  usually  results 
in  a  few  days  from  exhaustion.  When  the  process  is  neither 
septic  nor  extensive  recovery  frequently  follows. 

Treatment. — Restrict  the  diet.    Administer  opium  in  full 
\  doses  to  check  peristalsis  and  relieve  pain.     In  severe  cases 
the  drug  may  be  pushed  until  the  respiration  has  been  reduced 
I  to  twelve  per  minute ;  apply  leeches  to  the  abdomen,  and  fol- 
low  with  light  poultices.     In  some  cases  cold  cloths  are  more 
i   grateful  than  warm  applications.      In  non-perforating  cases, 
salines,  as  Epsom  or  Rochelle  salts  (3ij)j  may  be  given  until 
bowels  move  freely.     These  salts,  while  not  increasing  peri- 
stalsis, attract  serum  from  the  turgid  bloodvessels,  and  so 
relieve  congestion.     In  perforating  cases — and  these  are  the 
most  frequent — laparotomy  offers  the  only  hope  of  cure. 


ASCITES.  67 


Chronic  Peritonitis. 

Etiology. — It  is  usually  tuberculous ;  it  may  be  cancerous ; 
it  may  be  syphilitic  (occurring  in  young  children);  it  rarely 
follows  Bright's  disease  it  rarely  follows  an  acute  attack; 
it  occurs  in  chronic  alcoholism. 

Pathology. — The  intestines  are  matted  together  by  bands 
of  fibrous  lymph.  The  omentum  is  often  contracted  and 
greatly  thickened.  Effusion  is  usually  present,  but  it  varies 
considerably  in  amount ;  it  is  highly  albuminous,  and  in  the 
tuberculous  and  cancerous  varieties  it  may  be  bloody. 

Symptoms. — Fever  is  slight,  and  may  be  absent.  Pain  is  not 
severe,  and  is  commonly  paroxysmal.  There  is  usually  diffuse 
tenderness.     Ansemia  and  emaciation  may  be  marked. 

Inspection. — The  abdomen  is  generally  distended;  often 
irregularly,  from  sacculated  effusions,  inflated  intestinal  coils, 
or  the  projecting  matted  omentum. 

Palpation  may  detect  a  friction  fremitus,  and  the  irregulari- 
ties noted  above.     The  resistance  is  often  great. 

Pe7xusslon. — Dulness  in  the  flanks  with  superincumbent 
tympany.  AVhen  the  fluid  is  sacculated,  the  dulness  may  be 
irregularly  distributed.     Fluctuation  can  sometimes  be  elicited. 

Prognosis. — Unfavorable. 

Treatment, — Pest.  Light  diet  and  nutrient  tonics  (malt, 
cod-liver  oil).  Iodide  of  potassium  is  given  for  its  absorbent 
effect.  Iodine  may  be  applied  externally.  When  the  effu- 
sion is  great,  paracentesis  will  be  required.  In  the  simple  and 
tuberculous  forms  laparotomy  has  given  encouraging  results. 

ASCITES. 

Definition. — A  collection  of  serous  fluid  in  the  perito- 
neal cavity. 

Etiology. — (1)  It  may  result  from  one  of  the  common 
causes  of  dropsy,  viz :  Bright's  disease,  chronic  heart  disease, 
chronic  lung  disease,  anaemia,  and  especially  cirrhosis  of  the 
liver,  (2)  Pressure  of  a  tumor  or  displaced  viscus  upon  the 
portal  vein.  (3)  Chronic  peritonitis,  (4)  Pressure  upon  the 
thoracic  duct  (Chylous  ascites). 


68  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Symptoms. — When  tbe  effusion  is  large,  a  sensation  of 
weight,  dyspnoea,  scanty  urine,  constipation,  and  oedema  of 
the  feet  usually  result  from  pressure. 

Physical  Signs.  Inspection. — The  abdomen  is  distended, 
the  surface  is  smooth  and  shining;  the  base  of  the  thorax  is 
broadened ;  the  navel  is  more  or  less  obliterated ;  the  super- 
ficial veins  are  frequently  enlarged ;  and,  when  the  patient  lies 
in  the  dorsal  position,  the  flanks  bulge. 

Palpation  may  elicit  fluctuation,  and  in  the  flanks  a  sense 
of  resistance. 

Percussion. — Dulness  and  resistance  in  dependent  parts, 
with  superincumbent  tympany.  Dulness  is  movable;  it  is 
detected  in  the  flanks  when  the  patient  occupies  the  dorsal 
position. 

Aspiration. — The  fluid  is  usually  clear,  straw-colored,  and 
albuminous;  the  specific  gravity  is  from  1012-1016. 

Diagnosis.  Tympanites,  or  meteoiism. — This  yields  uni- 
versal hyper-resonance  on  percussion. 

Ovarian  Cysts. — The  enlargement  begins  in  the  iliac  fossa. 
The  dulness  is  more  or  less  immovable;  as  the  intestines  are 
pushed  aside,  there  is  dulness  anteriorly,  instead  of  tympany, 
as  in  ascites.  Vaginal  examination  furnishes  important  data; 
the  fluid  has  a  higher  specific  gravity  and  often  coagulates 
spontaneously. 

Distention  of  the  Bladder. — The  location  of  the  dulness  and 
resistance,  the  history,  and  the  results  of  catheterization  will 
render  the  diagnosis  apparent. 

Treatment. — When  possible,  endeavor  to  remove  the 
cause.  Encourage  free  catharsis  by  the  use  of  concentrated 
saline  solutions,  compound  jalap  powder  (gr.  xx-xxx),  ela- 
terium  (gr.  ^).  Encourage  free  diuresis  by  the  use  of  citrate 
of  caffeine  (gr.  iij— v),  infusion  of  digitalis  (f  3ss),  or  Niemeyer's 
pill  (page  80). 

^  Potassii  citrat.,  ^ss  ; 
Tinct.  scillae,  f  gss  ; 
Inf.  digitalis,    f.^iij  ; 
Aquse,  q.  s.  ad  f^vj. — M. 
Sig. — A  tablespoonful  thrice  daily. 

If  the  effusion  is  very  large,  if  the  stomach  is  irritable,  or 


DISEASES   OF  THE   PANCREAS.  69 

if   internal    remedies   fail    to   give   relief,   tapping   will    be 
required. 

DISEASES  OF  THE  PANCREAS. 

Until  very  recent  years  pathological  conditions  of  the  pan- 
creas have  excited  little  attention,  but  careful  study  reveals  the 
fact  that  the  organ  is  not  infrequently  the  seat  of  definite 
lesions  which  excite  well-marked  clinical  phenomena;  how- 
ever, in  the  present  state  of  medical  science  these  phenomena 
can  rarely  be  attributed  to  their  true  cause.  In  "bhronic  pan- 
creatic affections,  wasting,  fatty  stools,  and  glycosuria  are 
notable  symptoms. 

Pancreatic  Apoplexy. — A  profuse  hemorrhage  excites  sud- 
den pain  in  the  pancreatic  region,  vomiting,  abdominal  disten- 
tion, and  symptoms  of  collapse.     It  is  almost  invariably  fatal. 

Acute  Pancreafttis. — Causes  unknown.  The  pancreas  is 
enlarged,  ecchymosed,  and  sometimes  the  seat  of  fatty  degene- 
ration or  abscesses.  The  symptoms  are  pain,  fever,  vomiting, 
and  collapse. 

Cirrhosis  of  the  V&ncreSLS  {Chronic  Interstitial  PanGreatitis). 
—  It  probably  results  from  the  conditions  which  induce 
hepatic  cirrhosis,  viz.,  alcoholism,  syphilis,  etc.  The  pancreas 
is  contracted  and  hardened,  and  microscopic  examination 
reveals  an  overgrowth  of  connective  tissue  with  atrophy  of  the 
secreting  cells.  Glycosuria,  fatty  stools,  and  inanition  have 
been  attributed  to  it. 

Pancreatic  Calculi. — Concretions  from  the  pancreatic  juice 
sometimes  lodge  in  the  duct  of  Wirsung  and  excite  colic ; 
their  permanent  impaction  leads  to  the  formation  of  cysts. 

Cancer  of  the  Pancreas. — May  be  primary  or  secondary. 
The  most  common  seat  is  the  head  ;  the  most  common  variety 
is  the  scirrhus. 

Symptoms. — Pain,  rapid  emaciation,  fatty  stools,  an  im-\ 
movable  tumor   which   often    receives    a   pulsation  from  the 
underlying  aorta  ;    sometimes  jaundice. and  glycosuria. 


70  DISEASES   OE   THE   DIGESTIVE  SYSTEM. 

DISEASES  OF  THE  LIVER. 

The  liver  is  situated  in  the  right  hypochondrium,  with  a 
small  part  projecting  through  the  epigastrium  to  the  left  hypo- 
chondrium. 

Area  of  Liver  Duhiess.  —  The  absolute  dulness  (part  un- 
covered by  lung)  extends  in  the  mammary  line  from  the  upper 
border  of  the  sixth  rib  to  the  costal  margin ;  in  the  axillary 
line,  from  the  eighth  rib  to  the  eleventh  rib ;  in  the  scapular 
line,  from  tlie  ninth  rib  to  the  eleventh  rib  ;  in  the  median 
line,  the  upper  border  is  lost  in  the  cardiac  dulness,  while  the 
lower  border  lies  midway  between  the  ensiform  cartilage  and 
the  umbilicus.  Slight  dulness  in  the  mammary  line  begins  at 
the  fifth  rib. 

Palpation. 

Palpation  of  the  liver  is  practised  to  determine  position, 
size,  form,  and  consistence ;  and  to  detect  any  tenderness  or 
pulsation. 

Conditions  in  lokich  the  liver  is  palpable : — 

1.  In  thin  subjects,  the  edge  is  sometimes  palpable  under 
normal  conditions. 

2.  In  very  young  children,  in  whom  the  liver  is  always 
proportionately  large. 

3.  In  depression  of  the  liver,  as  by  a  pleural  effusion  or  by 
a  consolidated  lung. 

4.  When  the  suspensory  ligament  is  relaxed  and  the  liver 
"  wanders." 

6.  In  enlargement  from  any  cause. 
"     6.  In  certain  abnormalities  of  form,  as  in  the  "  tight-lace 
liver." 

Superficial  Irregulaidties.  —  Small  irregularities  may  be 
noted  in  cancer,  syphilis  of  the  liver,  and  atrophic  cirrhosis. 

Large  prominences  are  sometimes  noted  in  tumors,  abscesses, 
and  hydatid  cysts. 

Consistence. — The  liver  is  firm  to  the  touch  in  hypertrophic 
cirrhosis,  cancer,  congestion,  and  amyloid  disease.     In  abscess 


JAUNDICE   OR   ICTEEUS.  71 

and  hydatid  disease  the  resistance  is  less  marked,  and  some- 
times fluctuation  can  be  noted. 

Tenderness. — The  liver  is  tender  in  acute  congestion,  abscess, 
cancer,  and  in  affections  complicated  with  perihepatitis. 

Pulsation  may  be  detected  in  the  venous  congestion  resulting 
from  tricuspid  regurgitation,  abdominal  aneurism,  in  tumors 
of  the  left  lobe  resting  on  the  aorta,  rarely  in  aortic  regurgi- 
tation. 

Percussion. 

Percussion  determines  size  and  resistance. 

The  liver  is  uniformly  enlarged  in  ;  (1)  Congestion,  active 
and  passive.  (2)  Fatty  infiltration.  (3)  Amyloid  infiltration. 
(4)  Hypertrophic  cirrhosis.  (5)  Hypertrophy  as  in  leucaemia 
and  diabetes. 

Irregular  enlargements  of  the  liver  are  noted  in  :  (1)  Cancer. 
(2)  Abscess.     (3)  Hydatid  disease.     (4)  Syphilis. 

The  liver  is  diminished  in  size  in :  (1)  Atrophic  cirrhosis, 
late  stage.  (2)  Fatty  degeneration.  (3)  Acute  yellow  atrophy. 
(4)  Senile  atrophy.  The  area  of  hepatic  dulness  may  be 
diminished  from  certain  extrinsic  causes,  namely,  pulmonary 
emphysema  and  excessive  tympanites. 

JAUNDICE  OR  ICTERUS. 

Definition. — Pigmentation  of  the  tissues  and  secretions 
with  bile-pigments. 

Varieties.  —  (1)  Hepatogenous,  or  obstructive  jaundice. 
(2)  Hsematogenous,  or  non-obstructive  jaundice. 

Etiology  of  Hepatogenous  Jaundice.  —  Obstruction 
to  the  outflow  of  bile  leads  to  its  accumulation  and  re-absorp- 
tion. 

Obstruction  may  be  due  to  the  following  causes  : — 

1.  Stricture  of  the  bile-duct,  congenital  or  acquired. 

2.  Catarrh  of  the  bile-ducts,  or  of  the  duodenal  mucous 
membrane  around  the  orifice  of  the  ductus  choledochus. 

3.  Foreign  bodies  in  the  ducts;  as  gall-stones,  parasites. 

4.  Tumors  of  the  liver  or  of  adjacent  viscera  compressing  the 


72  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ducts.  Fecal  accumulations,  a  pregnant  uterus,  and  displaced 
organs  may  similarly  compress  the  ducts. 

5.  Lowered  blood  pressure  in  the  vessels  of  the  liver  causing 
increased  tension  in  the  bile-ducts,  as  in  the  simple  icterus  of 
the  new-born  or  that  following  depressing  emotions.  » 

Symptoms. — The  skin,  mucous  membranes,  and  secretions 
are  stained  yellow.  The  discoloration  is  usually  first  noticed 
in  the  conjunctivae.  The  stools  are  light,  the  urine  is  dark, 
and  in  bad  cases  resembles  porter.  The  pulse  is  usually  slow, 
and  the  temperature  slightly  subnormal.  There  is  always  some 
mental  depression,  and  in  extreme  cases  delirium,  convulsions, 
and  coma  may  develop.  Itching  of  the  skin  is  often  noted, 
and  urticaria  is  a  common  complication.  In  grav€  cases  sub- 
cutaneous ecchymoses  may  appear. 

Diagnosis. — Other  discolorations,  like  the  bronze  hue  of 
Addison's  disease,  and  the  green  tint  of  chlorosis,  must  be  dis- 
tinguished from  jaundice;  but  in  those  cases  the  conjunctiva 
is  white  and  the  urine  lacks  bile. 

Etiology  of  Hematogenous  or  Non-obstructive 
Jaundice. — This  form  results  from  a  disintegration  of  the 
blood,  or  a  destruction  of  the  liver  substance.  It  is  sometimes 
noted  in  pernicious  anaemia,  and  other  grave  anaemias,  but  it 
more  commonly  results  from  the  action  of  some  toxic  agent  on 
the  blood;  thus,  it  may  be  observed  in  poisoning  by  phos- 
phorus, arsenic,  and  other  minerals;  in  snake-poisoning,  in 
pyaemia,  and  in  certain  infectious  fevers — as  yellow  fever,  re- 
lapsing fever,  malarial  fever,  and  acute  yellow  atrophy. 

Symptoms. — Much  the  same  as  in  obstructive  jaundice,  but 
the  staining  of  the  skin  is  usually  not  so  intense,  the  stools 
still  contain  bile,  and  grave  cerebral  symptoms  are  more  apt 
to  develop. 

ICTERUS  NEONATORUM. 

Physiological  icterus  in  the  newborn  is  slight,  and  probably 
results  from  the  lowered  pressure  in  tlie  portal  vessels  caused 
by  ligation  of  the  umbilical  vein,  and  the  subsequent  absorp- 
tion of  bile  from  the  tense  capillary  ducts. 

Pathological  icterus  in  the  newborn  is  marked,  and  com- 


CATARRHAL   JAUNDICE.  73 

monly  proves  fatal.  It  results  from  congenital  stricture  of 
the  duct,  syphilis  of  the  liver,  or  septic  infection  through  the 
umbilical  vein. 

ACHOLIA. 

(Cholaemia,  Cholesteraemia.) 

This  term  is  applied  to  a  group  of  symptoms  noted  in  dis-  "• 
eases  associated  with  a  destruction  of  the  hepatic  substance, 
and  probably  dependent  upon  the  retention  of  poisons  which 
should  have  been  eliminated  by  the  liver. 

Etiology. — Acholia  occurs  in  acute  yellow  atrophy,  and 
sometimes  at  the  close  of  cancer,  cirrhosis,  and  fatty  degene- 
ration of  the  liver. 

Symptoms.  —  Delirium,    convulsions,    stupor,   and    coma.  "^ 
Jaundice  may  or  may  not  be  present.     Subcutaneous  ecchy- 
moses  and  hemorrhages  from  mucous  membranes  are  frequently 
observed. 

CATARRHAL  JAUNDICE. 

(Catarrhal  Hepatitis,  Catarrh  of  the  Bile-ducts.) 

Etiology. — (1 )  The  most  common  cause  is  the  extension 
of  a  gastro-duodenal  catarrh  into  the  ducts.  (2)  Primary  in- 
flammation of  the  ducts  may  result  from  exposure  to  cold  and 
wet.  (3)  It  may  be  induced  by  irritation  from  gall-stones. 
(4)  It  may  be  infectious,  complicating  malaria,  pneumonia, 
relapsing  fever,  and  similar  diseases. 

Pathology. — The  large  ducts  are  particularly  affected ; 
the  mucous  membrane  is  swollen  and  covered  with  tenacious 
mucus.  When  the  gall-bladder  is  compressed,  bile  is  ejected 
with  less  ease  than  is  natural  through  the  duodenal  orifice. 
When  the  catarrhal  process  is  long-continued,  ulceration  of 
the  ducts,  or  secondary  cirrhosis  (biliary  cirrhosis)  may  result. 

Symptoms.  —  (1)  Symptoms  of  gastro-duodenal  catarrh 
usually  precede.  These  are :  Coated  tongue,  anorexia,  fetid 
breath,  epigastric  distress,  vomiting,  and  perhaps  diarrhoea. 
(2)  Obstructive  jaundice,  indicated  by  yellow  skin  and  con- 
junctivse,  light  stools,  and  dark  urine.     (3)  In  acute  cases, 


74  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

slight  fever  and  swelling  of  the  liver,  which  is  tender  to  the 
touch. 

Diagnosis. — Usually  easy  ;  the  exclusion  of  other  causes 
of  jaundice,  and  the  consideration  of  the  age,  acute  onset,  and 
preservation  of  health  will  usually  make  the  diagnosis  appa- 
rent. 

Prognosis. — Favorable.  It  rarely  becomes  chronic  and 
leads  to  biliary  cirrhosis  and  ulceration  of  the  ducts.  The 
average  duration  is  from  a  few  days  to  several  weeks. 

Treatment. — Rest.  Liquid  diet.  Stupes  of  turpentine 
or  of  dilute  nitrohydrochloric  acid  may  be  applied  locally. 
Mild  laxatives  are  often  indicated  ;  calomel  may  be  selected. 

^   Hydrarg.  chlor.  mit.,  gr.  ij  ; 
Sodii  bicarb.,  3j. — M. 
Yt.  in  chart.  No.  xii. 
Sig. — One  every  hour  until  a  laxative  effect  is  produced. 

For  the  gastro-duodenal  catarrh,  mineral  waters^  subnitrate 
of  bismuth  (gr.  xx),  nitrate  of  silver  (gr.  ^  q.  d.},  chloride  of 
ammonium  (gr.  x,  q..  d.),  phosphate  of  sodium  (3j  q.  d.),  are 
valuable  adjuncts.  In  persistent  cases  the  daily  irrigation  of 
the  bowel  with  cold  water  (1-2  quarts)  has  been  highly  recom- 
mended ;  the  injections  stimulate  peristalsis  and  thus  favor  the 
expulsion  of  mucus  and  bile  from  the  ducts. 


BILIARY  CALCULI. 

(Gall-stones,  Cholelithiasis.) 

Definition. — Concretions  formed  in  the  gall-bladder,  and 
composed  for  the  most  part  of  bile-elements. 

Etiology. — Female  sex,  age  (after  forty),  heredity,  seden- 
tary habits,  a  rich  diet,  diseases  of  the  liver  w^hich  obstruct 
the  flow  of  bile,  as  tumors,  and  catarrh  of  the  ducts. 

Pathology. — The  stones  may  be  found  in  the  ducts,  but 
they  are  always  formed  in  the  gall-bladder.  There  may  be 
one  or  several  hundred.  When  multiple,  they  are  found  with 
facets,  from  attrition.  The  size  varies  from  a  grain  of  sand  to 
a  large  walnut.  The  color  varies  from  a  light  yellow  to  a 
dark  green.     The  chief  constituent  is  eholesteriu,  but  bile- 


BILIARY   CALCULI.  75 

acids,  bile-pigments,  lime,  and  magnesia  also  enter  into  tlieir 
composition.  On  section,  they  usually  present  a  concentric 
arrangement.  The  pathogenesis  is  not  known ;  a  chemical 
change  in  the  bile  probably  leads  to  a  precipitation  of  the 
cholesterin. 

Events. — (1)  Stones  often  remain  latent  in  the  bladder.  (2) 
They  may  pass  out  with  pain  and  spasm  (biliary  colic).  (3) 
Impaction.  A  stone  may  obstruct  the  cystic  duct  and  lead  to 
distention  of  the  bladder  with  mucus.  More  frequently  the 
common  duct  is  obstructed  near  its  duodenal  orifice,  when  the 
following  symptoms  result :  Permanent  jaundice,  tenderness, 
exacerbations  of  pain,  and  peculiar  paroxysms  of  fever,  chills, 
and  sweats,  resembling  malaria  (Charcot's  intermittent).  Such 
paroxysms  are  not  necessarily  dependent  on  suppuration, 
although  abscess  may  follow  obstruction.  (4)  Perforation 
into  the  abdominal  sac,  stomach,  or  intestine.  External  per- 
foration is  very  rare.  (5)  After  exit,  stricture  of  the  duct 
may  result  from  ulceration,  or  intestinal  obstruction,  from 
impaction. 

Symptoms  of  Biliary  Colic. — Sudden  and  intense  pain 
over  the  liver,  radiating  to  the  back  and  to  the  right  shoulder. 
It  usually  occurs  an  hour  or  two  after  eating.  A  rigor  with 
fever  may  mark  the  onset.  The  symptoms  of  intense  pain 
are  obvious — anxious  face,  cold  sweat,  feeble  pulse,  and  vomit- 
ing. Jaundice  may  follow  from  obstruction.  If  the  stone 
escapes,  it  may  be  found  in  the  stool. 

Diagnosis.  Renal  Colic. — Pain  radiates  from  the  kidney 
down  the  ureter  to  the  penis  ;  blood  in  the  urine ;  no  jaundice. 

Intestinal  Colic. — Pain  radiates  from  the  umbilicus;  flatu- 
lence ;  no  jaundice;  no  stone  recovered. 

Gastralgia. — Pain  referred  to  stomach  and  back ;  no  jaun- 
dice ;  no  stone  recovered. 

Prognosis. — The  attack  usually  ends  favorably.  Recur- 
rence is  common.  The  prognosis,  as  regards  ultimate  recovery, 
should  be  guardedly  favorable;  complications  are  comparatively 
rare. 

Treatment. — The  Attach. — Hot  fomentations.  Morphine 
(gr.  "I  to  I")  with  atropine  (gr.  yg-g)  hypodermically.  In  ag- 
gravated cases  anaesthetics  will  be  required. 


76  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

The  Interval. — A  regulated  diet,  largely  vegetable.  System- 
atic exercise  should  be  enjoined.  The  flow  of  bile  should  be 
encouraged  by  the  use  of  mineral  waters,  phosphate  of  sodium, 
or  a  vegetable  cholagogue,  like  podophyllin  or  euonymin. 
Catarrh  of  duets  should  be  relieved  so  that  stones  may  escape. 

In  impaction  the  same  treatment  is  indicated  with  counter- 
irritation,  and  the  use  of  some  intestinal  antiseptic,  such  as 
salol,  naphthol,  or  the  salicylate  of  bismuth,  to  replace  the 
antiseptic  elements  of  the  bile. 

In  aggravated  cases  an  exploratory  incision  should  be  made, 
when  a  stone  may  be  removed  from  the  common  duct  (chole- 
dochotomy),  or  from  the  gall-bladder  (cholecystotomy),  or  the 
gall-bladder  removed  (cholecystectomy). 


HYPEREMIA  OF  THE  L.IVER. 

Varieties. — (1)  Active  hypersemia.  (2)  Passive  hyper- 
semi  a. 

Etiology. — Active  hypercemia  is  commonly  due  to  dietetic 
indiscretions  (biliousness).  It  may  result  from  over-indulgence 
in  alcohol.  It  is  often  present  in  the  infectious  fevers.  It 
appears  to  arise  idiopathically  in  hot  climates. 

Passive  hyperemia  results  from  diseases  which  obstruct  the 
venous  circulation,  as  chronic  heart  and  lung  disease. 

Pathology. — The  liver  is  enlarged  and  filled  with  blood. 
In  the  passive  variety,  the  centre  of  the  lobule,  the  area  of  the 
hepatic  vein,  is  deeply  pigmented,  while  the  periphery,  the 
area  of  the  portal  vein,  is  pale.  This  mottled  appearance  has 
given  rise  to  the  term  "  nutmeg  liver."  In  persistent  cases, 
pigmentation,  atrophy  of  liver-cells,  and  overgrowth  of  con- 
nective tissue  result— -a  condition  termed  "cyanotic  indura- 
tion." 

Symptoms.  Active  hypermmia. — It  is  associated  with  gastric 
catarrh,  and  the  usual  symptoms  are  :  Coated  tongue,  fetid 
breath,  anorexia,  pain  and  tenderness  in  the  epigastric  and 
hypochondriac  regions,  nausea,  vomiting,  sick-headache,  and 
sometimes  slight  jaundice.     The  liver  may  be  enlarged 

In  the  passive  variety,  the  symptoms  are  the  same,  though 


CIRRHOSIS   OF   THE   LIVEE.  77 

less  marked.  The  liver  is  often  quite  large,  and  in  extreme 
cases,  such  as  follow  tricuspid  regurgitation,  it  may  pulsate. 

Prognosis. — In  simple  active  congestion  the  prognosis  is 
good.  In  passive  congestion  the  prognosis  depends  on  the 
cause. 

Treatment.  Active  hypercemia  from  dietetic  errors — Re- 
strict the  diet,  apply  counter-irritants,  and  administer  calomel 
and  soda,  thus  : — 

^  Hydrarg.  chlor.  mit.,  gr.  j  ; 
Sodii  bicarb.,  ^j. — M, 
Pt.  iu  chart.  No.  vi. 
Sig. — One  every  hour  until  three  or  four  have  been  taken. 

Follow  the  calomel  with  a  laxative  dose  of  sodium  phos- 
phate, Carlsbad  or  Rochelle  salts. 

In  recurring  attacks  of  biliousness,  in  addition  to  dietetic 
and  hygienic  directions,  the  following  will  prove  useful : — 

^  Mass.  hydrarg.,  gr.  v; 
Pulv.  rhei, 

Ext.  gentian.,  aa  ^ss  ; 

01.  caryophyll.  gtt.  iv. — M.     (Hartshorne.) 
Div.  in  pil.  No.  xx. 

Sig. — One  or  two  occasionally,  as  directed  ;  to  be  continued  if  re- 
quired, thrice  daily  for  several  days. 

In  passive  congestion,  direct  the  treatment  to  the  original 
disease.  In  mild  cases  the  mineral  waters  do  well  (Carlsbad, 
Congress,  and  Friederichshall).  A  mercurial  laxative  may  be 
used  from  time  to  time.  In  obstinate  cases  the  concentrated 
salines  may  be  employed  as  purgatives,  and  wet  cups  applied 
to  the  liver. 

CIRRHOSIS  OF  THE  LIVER. 

(Hob-nailed  Liver,  Interstitial  Hepatitis,  Gia-drinker's  Liver.) 

Definition. — A  chronic  disease  characterized  anatomically 
by  a  hyperplasia  of  the  connective  tissue  and  destruction  of 
the  secreting  cells,  and  manifested  chiefly  by  symptoms  of 
portal  obstruction. 

Etiology. — Male  sex  and  middle  life  are  generally  predis- 
posing factors.     (1)  The  abuse  of  spirituous  liquors  is  a  com- 


78  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

mon  cause.  (2)  It  follows  chronic  diseases  which  alter  the 
crasis  of  the  blood,  viz  :  Syphilis,  gout,  malaria,  and  tubercu- 
losis. (3)  It  results  from  the  passive  congestion  induced  by 
chi^onic  heart  and  lung  disease.  (4)  It  may  be  secondary  to 
inflammation  of  the  bile-ducts.  It  is  sometimes  seen  in 
children  ;  and  in  them,  congenital  syphilis  and  the  infectious 
fevei-s  appear  to  be  the  exciting  causes. 

Pathology. — Two  varieties  have  been  recognized  :  (1) 
Atrophic  cirrhosis,  and  (2)  hypertrophic  cirrhosis. 

Atrophic  Cirrhosis. — In  the  early  stages  the  liver  is  some- 
what large  from  hypersemia.  In  the  advanced  stage  the 
liver  is  small,  firm,  gray  in  color,  and  covered  with  numerous 
granulations  ("  hob-nails").  A  section  of  the  liver  presents 
a  network  of  fine  and  of  coarse  pearly  bands  of  connective 
tissue.  The  contraction  of  this  connective  tissue  is  responsi- 
ble for  the  reduction  in  size  and  granular  surface. 

Microscopic  examination  reveals  an  overgrowth  of  connective 
tissue;  and,  from  interference  with  nutrition,  fatty  infiltration, 
fatty  degeneration,  atrophy  of  cells,  and  pigmentation. 

Hypertrophic  Cirrhosis. — This  term  has  been  applied  to  the 
first  stage  of  the  atrophic  form,  and  to  a  large  liver  resulting 
from  the  combination  of  cirrhosis  with  fatty  infiltration. 

More  recently,  the  term  hypertrophic,  or  biliary  cirrhosis, 
has  been  restricted  to  a  condition  in  which  the  connective- 
tissue  hyperplasia  starts  from  the  periphery  of  the  capillary 
bile-ducts  instead  of  from  the  ramifications  of  the  portal  vein, 
as  in  atrophic  cirrhosis.  The  symptoms  of  portal  obstruction 
are  not  marked,  but  jaundice  is  a  prominent  feature. 

The  liver  is  large,  yellow  in  color,  and  its  surface  is  smooth 
or  finely  granular.  The  increased  size  is  due  to  a  great  over- 
growth of  connective  tissue,  and  to  preservation  of  the  hepatic 
parenchyma. 

Symptoms  of  Atrophic  Cirrhosis. — Obstruction  to  the 
portal  circulation  induces  congestion  of  the  stomach  and  intes- 
tines, and  hence  the  initial  symptoms  are  those  of  gastro-intes- 
tinal  catarrh.  These  are:  Coated  tongue,  anorexia,  fulness  and 
distress  after  eating,  vomiting  of  frothy  mucus,  flatulence,  con- 
stipation, and  dark  urine.  These  phenomena  may  last  for 
months  or  years. 


CIRRHOSIS   OF   THE   LIVER.  79 

As  the  obstruction  becomes  greater,  the  portal  blood  finds 
new  channels,  and  'the  superficial  abdominal  veins  enlarge, 
notably  around  the  umbilicus,  fiDrming  the  so-called  "  caput 
medusae."     Hemorrhoids  result  from  the  same  cause. 

Engorgement  of  the  portal  system  leads  to  ascites  and  swell- 
ing of  the  feet,  to  hemorrhage  from  the  stomach,  bowel,  or  some 
distant  organ,  and  to  enlargement  of  the  spleen. 

Physical  Examination. — The  liver  is  at  first  large,  but  is 
subsequently  contracted. 

There  is  loss  of  flesh  and  strength.  The  skin  is  muddy  in 
appearance.  Jaundice  is  not  common,  and  when  present, 
results  from  catarrh  of  the  bile-ducts.  Death  results  from 
exhaustion,  hemorrhage,  intercurrent  disease,  or  from  a  group 
of  cerebral  symptoms  (delirium,  convulsions,  and  coma)  which 
are  probably  due  to  the  retention  of  some  toxic  agent  which 
the  liver  should  eliminate. 

Hyperti-ophie  Cirrhosis. — Jaundice  is  marked.  The  liver  is 
enlarged,  smooth,  and  firm.  Symptoms  of  portal  obstruction, 
such  as  dropsy  and  hemorrhages,  are  not  marked.  The  spleen 
is  swollen.  The  disease  may  last  one  or  two  years,  but  an  abrupt 
termination  in  convulsions  and  coma  may  occur  at  any  time. 

Complications. — Tuberculosis,  interstitial  nephritis,  cardiac 
hypertrophy,  and  hemorrhage. 

Diagnosis. — In  the  early  stage  the  diagnosis  can  only  be 
suspected.  In  the  drunkard,  chronic  gastric  catarrh  with  en- 
largement of  the  liver  would  strongly  indicate  cirrhosis. 

Cancer. — History,  greater  cachexia,  jaundice  more  common, 
and  ascites  less  frequent,  liver  enlarged  and  studded  with 
nodules,  other  organs  affected,  pain,  and  short  duration. 

Chronic  Peritonitis  with  effusion. — This  is  usually  tuberculous 
or  cancerous.  The  short  duration,  the  abdominal  tenderness, 
the  lack  of  a  uniform  enlargement  from  bands  of  lymph,  the 
absence  of  symptoms  indicating  portal  obstruction,  the  normal 
size  of  the  liver,  after  tapping,  and  the  turbid  sanious  fluid 
will  indicate  chronic  peritonitis. 

Prognosis. — Unfavorable.  It  may  be  arrested  in  the  early 
stage.  The  entire  duration  may  be  many  years,  but  death 
usually  results  in  from  one  to  three  years  after  symptoms  of 
portal  obstruction  have  appeared. 


80  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

Treatment. — Light  nutritous  diet.  Rest.  Alcohol  must 
be  interdicted.  Treat  the  gastric  catarrh  with  nitrate  of  silver, 
bismuth,  mineral  waters,  and  antiseptics  (creosote  or  salicylate 
of  bismuth).  Iodide  of  potassium  in  small  doses,  well  diluted, 
may  be  of  service  in  the  early  stage.  Coimter-irritation  over 
the  liver  should  be  frequently  practised. 

Ascites. — Concentrated  saline  purges  in  the  morning  (Epsom 
salts  Iss  in  enough  water  to  dissolve  it).  Diuretics,  as  digitalis 
or  caffeine.     Niemeyer's  pill  may  be  useful : 

^   Mass.  hydrarg.,  gr.  xij  ; 

Pulv.  digitalis,  gr.  xij  ; 

Pulv.  scillse,  gr.  xij. — M. 
Ft.  in  pil.  No.  xii. 
Sig. — One  pill  thrice  daily. 

When  the  effusion  is  very  large,  internal  remedies  fail,  and 
paracentesis  will  be  required. 

The  Operation.- — Empty  the  bladder.  Ansesthetize  a  point 
in  the  linea  alba  midway  between  the  umbilicus  and  pubis. 
Tap  with  a  small  trocar,  and  have  a  long  rubber  tube  at- 
tached to  the  canula  for  conveying  the  liquid  into  a  conve- 
nient receptacle.  When  the  liquid  stops  flowing  withdraw  the 
canula,  cover  the  wound  with  adhesive  plaster,  and  apply  an 
abdominal  binder.  Observe  strict  antisepsis.  The  operation 
is  free  from  danger. 

ABSCESS  OF  THE  LIVER. 

Ktiology. — (1)  The  presence  in  the  liver  of  the  amoeba  coli 
of  dysentery.  (2)  Traumatism.  (3)  Foreign  bodies,  gall- 
stones, retained  bile,  and  hydatid  cysts.  (4)  Septic  emboli ; 
they  may  come  through  the  hepatic  artery,  but  usually  they 
come  through  the  portal  vein  from  gastric  ulcers,  or  the  ulcers 
of  dysentery,  typhlitis,  or  typhoid  fever,  and  produce  a  puru- 
lent inflammation  of  the  vein  (suppurative  pylephlebitis). 

Pathology. — The  abscess  following  amoebic  dysentery  is 
often  single,  and  usually  occupies  the  right  lobe. 

Embolic  abscesses  are  always  multiple. 

Events. — Hepatic  abscess  may  kill  by  exhaustion  or  by 
rupture   into   adjacent  viscera.     Recovery  may  follow  after 


CANCER    OF    THE   LIVER.  81 

operation  or  spontaneous  evacuation  ;  and  the  latter  may  be 
external, through  the  bronchial  tubes,  or  through  the  bowel. 

Symptoms. — Hectic  symptoms  :  Fever,  high  in  the  evening 
and  low  in  the  morning,  sweats,  and  chills.  Local  symp- 
toms :  The  liver  is  enlarged,  painful,  and  tender.  There  may 
be  bulging  and  even  fluctuation.  Pus  may  be  detected  by  the 
aspirating  needle.  Jaundice  from  obstruction  is  sometimes 
present. 

Diagnosis.  Hydatid  Cysts. — Long  duration,  history,  clear 
fluid  on  aspiration,  absence  of  pain,  and  absence  of  hectic 
symptoms. 

Cancer. — History,  cachexia,  the  involvement  of  other  organs, 
multiple  and  firm  nodules,  and  absence  of  hectic  symptoms. 

Intermittent  Fever  due  to  Impacted  Calculi. — Fever  and  pain 
are  periodic ;  the  liealth  may  be  well  preserved ;  the  liver  is 
not  enlarged.     The  coudition   may  persist  for  several  years. 

Prognosis. — Embolic  abscesses  (multiple)  prove  invariably 
fatal.  Traumatic  abscesses  or  abscesses  due  to  a  amoebic 
dysentery  may  terminate  favorably  after  spontaneous  or  in- 
duced evacuation. 

Treatment. — Hot  applications,  opium,  quinine,  and  stimu- 
lants. When  the  history  indicates  a  single  abscess,  invoke  sur- 
gical aid. 

CANCER  OF  THE  LIVER. 

Etiology. — Male  sex,  age  (after  forty),  heredity,  and  trau- 
matism are  predisposing  factors. 

Pathology. — It  is  generally  secondary.  The  liver  is  en- 
larged, and  studded  with  numerous  grayish-white  nodes,  some 
of  which  project  from  the  surface.  The  superficial  nodes  are 
often  depressed  at  the  centre. 

Symptoms. — (1)  Severe  pain  and  tenderness.  (2)  Cachexia, 
i.  e.  loss  of  flesh  and  strength,  with  pallor.  (3)  Pressure- 
symptoms  :  jaundice  is  common  but  ascites  is  rare.  (4)  Phy- 
sical examination  :  the  liver  is  enlarged,  its  surface  is  nodular, 
and  the  central  depression,  or  umbilications,  can  often  be 
detected.  (5)  Symptoms  of  the  primary  growth  which  is 
usually  in  the  stomach. 


82  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

Fever  is  generaly  absent,  but  secondary  perihepatitis  or 
suppuration  of  the  cancerous  nodules  may  induce  it. 

Diagnosis.  Hypertrophic  Cirrhosis. — Liver  is  smooth  and 
painless,  the  duration  is  longer,  cachexia  is  not  marked,  and 
there  is  no  indication  of  a  primary  cancer. 

Hydatid  Cysts. — Health  preserved,  tumor  elastic  or  fluctuat- 
ing, no  pain,  jaundice  uncommon,  aspiration  yields  a  clear 
fluid  containing  booklets. 

Abscess. — History,  short  duration,  hectic  fever,  and  results 
of  aspiration. 

Prognosis.  —  Absolutely  fatal.  Duration,  from  a  few 
months  to  a  year. 

Treatment. — Palliative. 

AIMYLOID  LIVER. 

(Waxy  Liver,   Lardaceous  Liver.) 

Definition. — An  enlargement  of  the  liver  due  to  the  de- 
position of  an  albuminoid  substance. 

Etiology. — (1)  Prolonged  suppuration  ;  (2)  syphilis  ;  (3) 
tuberculosis,  and  (4)  chronic  malaria  are  causal  factors. 

Pathology. — The  liver  is  very  large,  hard,  and  smooth. 
The  edge  is  blunt.  On  section,  the  surface  is  "  waxy,"  and  a 
dilute  solution  of  iodine  strikes  a  mahogany-red  color  with  the 
amyloid  material.  The  degenerative  process  begins  in  the 
wails  of  the  capillaries  and  spreads  to  the  connective  tissue. 

Symptoms. — Failure  of  general  health  with  anaemia.  The 
liver  is  enlarged,  smooth,  firm,  and  painless,  and  presents  a 
blunt  edge.  The  spleen  and  kidneys  share  in  the  degeneration, 
and,  as  a  result,  the  spleen  is  enlarged  and  the  urine  is  albu- 
minous. 

Diagnosis. — The  history,  the  smooth,  painless,  enlarge- 
ment of  the  liver  without  jaundice,  and  the  involvement  of  the 
kidneys  and  spleen,  are  the  diagnostic  phenomena. 

Prognosis. — Unfavorable. 

Treatment. — Remedies  must  be  directed  to  the  causal 
disease.  Nutrients  and  tonics  are  indicated.  Absorbents,  like 
the  iodides,  mercurials,  and  ammonium  chloride,  have  been 
recommended,  but  are  valueless. 


HYDATID   CYSTS   OF   THE   LIVER,  83 

HYDATID  CYSTS  OF  THE  LIVER. 

(Echinococcus  of  the  Liver.) 

Etiology  and  Pathology. — Hydatid  cysts  are  formed 
by  the  embryos  of  the  tseuia  echinococcus,  a  small  tape-worm 
inhabitino^  the  intestines  of  the  dog;. 

The  eggs  of  the  worm  are  accidentally  ingested  by  man,  and 
embryos  are  liberated  in  the  stomach,  whence  they  may  migrate 
to  any  organ  ;  the  liver  however  is  most  commonly  affected 
through  the  portal  vein.  The  fixed  embryo  soon  develops 
into  a  cyst  which  is  composed  of  an  external  laminated  layer 
and  an  internal  breeding  layer.  A  connective-tissue  layer  is 
formed  on  the  outside  from  irritation. 

The  cyst  contains  a  clear  non-albuminous  fluid  which  has  a 
specific  gravity  of  1005  to  1007,  and  which  is  rich  in  chlorides. 

Scolices  or  larvse  develop  from  the  breeding  layer ;  they 
are  provided  with  four  suckers  and  a  circle  of  booklets,  and 
produce  daughter-cysts  within  the  parent-cyst.  When  ingested 
by  the  dog  the  larvae  develop  into  mature  tape-worms. 

Symptoms. — Small  cysts  excite  no  symptoms.  There  is 
often  a  slowly-developing,  irregular  enlargement  of  the  liver ; 
if  the  cyst  is  superficial,  an  elastic  or  fluctuating  mass  may  be 
detected  on  palpation. 

On  percussion  a  peculiar  vibratory  sensation  (hydatid  thrill) 
may  be  imparted  to  the  hand.  Aspiration  yields  a  clear  fluid 
containing  booklets  and  chlorides. 

Fever,  pain,  and  jaundice  are  usually  absent. 

Events. — (1)  It  may  reach  a  certain  size,  and  then  remain 
latent.  (2)  Trifling  injury  may  convert  it  into  an  abscess. 
(3)  Rupture  of  the  cyst  externally  or  into  neighboring  organs 
may  result  in  death  or  in  recovery. 

Diagnosis. —  Slow  development,  irregular  enlargement, 
elastic  feel,  the  results  of  aspiration,  and  the  absence  of  pain, 
fever,  and  jaundice  are  the  diagnostic  features.  Suppurating 
cysts  will  be  diagnosed  abscesses.  An  upward-growing  cyst 
may  present  the  signs  of  a  pleural  efiusion. 

Prognosis. — Guardedly  favorable. 

Treatment. — When  large,  aspirate.  If  the  fluid  re-collects, 
open  and  drain. 


•84  DISEASES   OF  THE    DIGESTIVE   SYSTEM. 

ACUTE  YELLOW  ATROPHY. 

(Acute  Parenchymatous  Hepatitis;  Malignant  Jaundice.) 

Definition. — A  rare  and  grave  disease  characterized  ana- 
tomically by  a  rapid  destruction  of  the  liver  tissue,  and  mani- 
fested by  jaundice,  -hemorrhages,  a  reduction  in  the  size  of  the 
liver,  and  marked  cerebral  phenomena. 

Etiology. — Female  sex,  pregnancy,  early  life,  are  predis- 
posing factors. 

Alcoholic  excesses,  emotional  excitement,  and  sypTiilis  have 
been  given  as  exciting  causes. 

The  rapid  course,  widespread  lesions,  and  the  fact  that  it 
has  occurred  endemically  suggest  an  infectious  origin. 

Pathology. — From  destruction  of  its  substance  the  liver 
is  quite  small.  The  capsule,  being  too  large  for  the  shrunken 
organ,  is  wrinkled.     The  surface  is  yellowish-red  and  mottled. 

Histology. — Fat  drops,  molecular  debris,  fat  crystals,  and 
crystals  of  leucin  and  tyrosin  take  the  place  of  normal  liver- 
cells.     The  other  organs  reveal  fatty  degeneration. 

Symptoms. — (1)  The  initial  symptoms,  which  are  those  of 
catarrhal  jaundice,  are  :  Malaise,  slight  fever,  coated  tongue, 
nausea,  vomiting,  and  jaundice.  (2)  Nervous  symptoms  fol- 
low ;  these  are :  Severe  headache,  delirium,  convulsions,  and 
coma.  Sometimes  these  symptoms  precede  the  jaundice.  (3) 
The  urine  is  scanty,  and  contains  albumin,  blood,  tube-casts, 
and  crystals  of  leucin  and  tyrosin.  (4)  Hemorrhages  are  com- 
mon, the  skin  may  be  covered  with  ecchymoses,  and  bleeding 
from  the  mucous  membranes  may  occur.  (5)  The  area  of 
hepatic  dulness  is  diminished,  but  the  area  of  splenic  dulness 
is  increased. 

Diagnosis. — The  grave  cerebral  symptoms,  reduced  hepatic 
dulness,  and  hemorrhages  will  separate  it  from  catarrhal  jaun- 
dice. 

Phospliorus-poisoning. — History,  phosphorus  in  the  urine, 
primary  enlargement  of  the  liver,  and  the  great  severity  of 
the  initial  gastric  symptoms. 

Prognosis — Almost  invariably  fatal.  Death  results  within 
a  week  after  the  appearance  of  cerebral  symptoms. 

Teeatment. — Palliative. 


DISEASES 

OF 

THE    KIDNEYS 


THE  URINE. 

Normal  urine  is  a  pale,  amber-colored  fluid,  of  acid  reaction, 
having  a  specific  gravity  of  1015  to  1025,  and  amounting  in 
quantity  to  about  fifty  ounces  in  twenty-four  hours. 

Pol3^ria. — An  increased  flow  of  urine. 

Temporary  polyuria  results  from  :  (1)  Excessive  ingestion 
of  fluids.  (2)  Diuretics.  (3)  Suppression  of  perspiration.  (4) 
Crises  of  certain  febrile  diseases,  and  certain  neurotic  manifes-^' 
tations,  such  as  excitement,  neuralgia,  and  hysteria.  (5)  Ab- 
dominal enlargements,  as  in  pregnancy,  effusions,  and  tumors. 
(6)  Removal  of  vSome  temporary  obstruction  in  the  urinary 
passages. 

Permanent  polyuria  results   from  :    (1)  Diabetes  mellitus. 

(2)  Diabetes  insipidus.  (3)  Chronic  interstitial  nephritis.  (4) 
Amyloid  kidney. 

The  urine  is  diminished  or  suppressed  (anuria)  in  the  fol- 
lowing conditions :  (1)  Excessive  secretion  through  other 
channels,  as  in  free  perspiration  and  diarrhoea.     (2)  In  fever. 

(3)  Passive  renal  congestion,  from  obstructive  heart,  lung,  or 
liver  dSease.  (4)  Organic  obstruction  in  the  urinary  pass- 
ages. (5)  In  acute  and  chronic  parenchymatous  nephritis. 
(6)  Nervous  causes,  as  in  hysteria,  and  in  the  reflex  inhibition 
after  abdominal  injuries  or  operations. 

Urea. — Urea  results  from  the  perfect  decomposition  of  the 
nitrogenous  elements  of  food  and  tissues.    It  is  perfectly  solu- 

(85) 


86  DISEASES   OF  THE   KIDNEYS. 

ble  in  urine,  but  the  nitrate  of  urea  crystallizes  in  the  form  of 
transparent  imbricated  plates  when  nitric  acid  is  added  to  urine 
that  has  been  partially  evaporated. 

The  amount  of  urea  excreted  varies  greatly  in  health.  Nor- 
mal urine  contains  about  2  to  2^  per  cent,  of  urea. 

It  is  inereased:  (1)  After  the  ingestion  of  much  albuminous 
food.  (2)  After  exertion.  (3)  In  acute  inflammatory  pro- 
cesses and  in  fevers.     (4)  In  diabetes. 

It  is  diminished:  (1)  In  nephritis.  (2)  In  organic  diseases 
of  the  liver.  (3)  In  wasting  diseases  and  in  anaemia.  (4)  In 
starvation. 

Fowler's  Hypochlorite  Test  for  Urea. — Add  to  1  volume  of 
the  urine  7  volumes  of  Labarraque's  solution  of  chlorinated 
soda.  Shake  the  jar  containing  the  mixture  occasionally,  and 
stand  it  aside  for  two  hours,  when  the  urea  will  have  been 
decomposed.  Now  take  the  specific  gravity  of  the  quiescent 
fluid. 

2d.  Ascertain  the  specific  gravity  of  the  mixture  of  urine  and 
Labarraque's  solution  before  decomposition.  To  do  this,  mul- 
tiply the  specific  gravity  of  the  pure  Labarraque's  solution  by 
7,  add  this  to  the  specific  gravity  of  the  pure  urine,  and  divide 
by  8.  The  result  is  the  specific  gravity  of  the  mixed  fluid. 
From  this  subtract  the  specific  gravity  of  the  quiescent  mix- 
ture after  decomposition  of  the  urea,  multiply  the  difi^erence 
by  .77,  and  the  result  is  the  percentage  of  urea. — Tyson. 

Lithuria. — Uric  acid  or  urates  in  the  uriue.  These  sub- 
stances are  formed  by  the  imperfect  metamorphosis  of  tissues 
and  nitrogenous  food.  When  they  are  in  excess  the  urine  is 
heavy,  dark  in  color,  and  on  cooling  throws  down  a  brick-red 
deposit,  termed  "  lateritious"  (later,  a  brick). 

Microscopically,  uric  acid  appears  as  reddish-yellow  rhombic 
prisms  or  lozenge-shaped  crystals. 

Amorphous  urates  appear  as  fine,  dark,  and  opaque  granules. 

Crystalline  urates  appear  as  needles,  dumb-bells,  or  as 
globular  masses  from  which  sharp  spines  project. 

Murexide  Test  for  Uric  Acid  and  its  Salts. — Evaporate  a  little 
urine  in  a  porcelain  dish,  add  a  drop  or  two  of  strong  nitric 
acid,  and  heat  again  to  dryness.     Cool,  and  add  a  drop  of 


THE    UPvINE. 


87 


liquor  ammouise^  and  the  beautiful  purple  color  of  murexide 
is  developed. 

Fig.  3. 


Uric  acid  and  uric  acid  salts. 

Urates. — The  urates  are  present  in  small  quantity  in  normal 
urine.     They  may  become  perceptible  or  transiently  increased  : 

(1)  In  urine  exposed  to  a  cold  atmosphere.  (2)  In  urine  made 
scanty  by  free  perspiration  or  diarrhoea.  (3)  When  the  acidity 
of  the  urine  is  temporarily  increased.  (4)  After  the  excessive 
indulgence  in  nitrogenous  food. 

The  urates  are  increased  pathologically  in  many  diseases 
which  directly  or  indirectly  interfere  with  tissue  or  food  metab- 
olism,   notably    in :    (1)    Lithsemia    or   the   gouty    diathesis.  ^ 

(2)  Fever.  (3)  Extreme  anaemia,  (4)  Diseases  of  the  lungs — ■ 
from  interference  with  oxidation. 

Leucin  and  Tyrosin. —  These  substances  are  found  in  the  urine  \ 
in  certain  specific  fevers,  in  grave  anaemia,  and  especially  in  \ 
fatty  degeneration   of  the  liver  resulting  either  from  phos- 
phorus-poisoning or  acute  yellow  atrophy. 

They  may  be  detected  by  evaporating  a  few  drops  of  the 
urine  on  a  glass  slide.  Leucin  appears  in  the  form  of  small, 
round,  glistening  spheres,  resembling  fat  drops,  but  unlike  the 
latter  they  are  insoluble  in  ether,  Tyrosin  appears  in  the 
form  of  intersecting  tufts  of  fine  acicular  crystals. 


88 


DISEASES    OF   THE    KIDNEYS. 

Fig.  4. 


a.  Trrosin  crrstals.    b.  Leucin  crystals. 

Phosphates. — There  are  two  forms,  amorphous  and  crystal- 
line. 

Amorphous  earthy  j)liosphcdes  are  found  in  alkaline  urine, 
and  are  precipitated  by  adding  a  few  drops  of  liquor  ammonise 
to  the  urine. 

Crystallized  'phosphate  of  lime  appears  as  stellar  or  rod- 
shaped  crystals  which  are  soluble  in  acetic  acid. 

Fig.  5. 


Triple  phosphate. 


The  ammonio-magnesian  phosphate,  or  triple  phosphate,  ap- 
pears in  decomposing  urine  as  transparent  coffin-shaped  prisms. 
They  may  resemble  crystals  of  oxalate  of  lime,  but,  unlike 
the  latter,  are  freely  soluble  in  acetic  acid. 


THE    UEINE.  89 

The  presence  of  phosphates  in  the  urine  is  no  indication  of 
excess,  for  when  normal  in  amount  they  are  often  precipitated 
in  urine  that  is  temporarily  alkaline. 

The  detection  of  triple  phosphates  in  newly-voided  urine 
indicates  decomposition  in  the  bladder,  a  condition  resulting 
from  vesical  catarrh. 

Phosphates  are  often  increased  in  nervous  dyspepsia,  melan- ) 
cholia,  and  neurasthenia. 

Chlorides. — -The  quantity  of  these  salts  is  increased :    (1) 
After  exertion.     (2)  During  the  absorption  of  mechanical  or 
inflammatory  effusions.     (3)  In  intermittent  fever,  from  the^ 
destruction  of  corpuscles. 

The  quantity  is  decreased :  (1)  In  most  febrile  diseases. 
(2)  In  nephritis.  (3)  In  many  wasting  diseases,  (4)  Espe- 
cially in  pneumonia. 

Test. — We  may  thus  roughly  estimate  the  quantity.  Add 
a  few  drops  of  strong  nitric  acid  to  the  urine,  remove  any 
albumin  that  may  be  present,  and  then  add  to  the  clear  urine 
a  little  of  a  strong  solution  of  nitrate  of  silver.  The  abund- 
ance of  the  white  precipitate  will  indicate  the  quantity  of  chlo- 
rides present. 

Fig.  6. 


Oxalate  of  lime. 

Oxaluria. — Oxalate  of  lime  appears  in  the  urine  as  dumb- 
bell-shaped crystals,  or  as  minute  highly  refracting  octahedra. 


( 


90  DISEASES    OF   THE   KIDNEYS. 

Many  conditions  produce  them.  They  are  found  :  (1)  After 
eating  certain  fruits  and  vegetables,  as  rhubarb,  cauliflower, 
and  pears.  (2)  In  certain  diseases,  notably  nervous  dyspepsia, 
hypochondria,  melancholia,  diabetes,  and  wasting  diseases. 

In  these  cases  the  oxalates  result  from  the  imperfect  metab- 
olism of  organic  substances. 

Urobilinuria. — Urobilin  is  a  coloring  principle  derived  from 
the  blood.  AVhen  present  in  the  urine  in  large  amount  it  pro- 
duces a  reddish-brown  color  ;  Avhen  deposited  in  the  tissues  it 
produces  a  form  of  jaundice  which  has  been  called  urobilin- 
icterus  (Jaksch). 

Urobilinuria  occurs:  (1)  Occasionally  in  health.  (2)  In 
pyrexia.  (3)  After  the  absorption  of  hemorrhagic  eflFusions. 
(4)  In  liver  disease.     (5)  In  grave  anaemia. 

GlUCOSUria,  or  Glycosuria. — Glucose  in  the  urine. 

Its  Causes. — (1)  iN'ormal  urine  contains  a  trace.  (2)  Diabetes 
mellitus.  (3)  Certain  diseases,  as  gout,  chorea,  tetanus,  and 
functional  nervous  affections.  (4)  Ingestion  of  much  sacchar- 
ine or  amylaceous  material.  (5)  Pregnancy.  (6)  Toxic  sub- 
stances in  the  blood,  as  the  nitrites  and  carbon  monoxide. 

Qualitative  Tests  for  Glucose. — The  copper  tests  are  commonly 
employed,  and  depend  on  the  power  ^vhich  glucose  possesses  of 
converting  blue  oxide  of  copper  into  the  orange-yellow  sub- 
oxide. 
"  Trommer^s  Test. — Add  to  the  suspected  urine  half  its  volume 
'  of  liquor  potassse,  and  if  any  precipitate  falls  filter  the  solution  ; 
then  add  one  or  two  drops  of  a  weak  solution  (1-30)  of  sulphate 
of  copper,  and  heat  the  resulting  mixture.  If  sugar  is  present, 
a  dense  yellow  or  red  precipitate  falls. 

Simple  decolorization  of  the  fluid  is  no  proof  of  sugar. 

Fehling^s  Test. — As  the  fluid  employed  in  this  test  spoils  on 
keeping,  it  should  be  freshly  prepared  when  required  by  mix- 
ing in  equal  proportions  the  following  solutions  : — 

JFirst  solution  :  Dissolve  34.64  grams  of  pure  cupric  sul- 
phate in  distilled  water,  and  dilute  up  to  500  cubic  centi- 
meters. 

Second  solution:  Dissolve  180  grams  of  pure  Rochelle  salt 
and  70  grams  of  caustic  soda  in  400  cubic  centimeters  of  dis- 


THE   URINE.  91 

tilled  water,  and  heat  to  boiling ;  on  cooling,  make  up  to  500 
cubic  centimeters  witli  distilled  water. 

To  about  ten  minims  of  each  solution  in  a  test-tube  add 
about  a  fluid  drachm  of  distilled  water,  and  boil  for  a  few  sec- 
onds ;  if  the  solution  remains  clear,  add  the  suspected  urine 
drop  by  drop,  and  occasionally  heat  the  tube.  If  sugar  is 
abundant,  a  yellowish-red  deposit  will  be  produced.  If  no 
precipitate  falls,  continue  the  addition  of  the  urine  until  an 
equal  volume  has  been  added,  and  allow  to  cool ;  then  if  no 
precipitate  falls,  sugar  is  absent. 

The  Fhenyl-hydrazin  Test. — Put  in  a  test-tube  half  filled 
with  water  phenyl  hydrazin  (hydrochlorate)  2  grains  and  so- 
dium acetate  3  grains.  Dissolve  by  heating.  Fill  the  tube 
with  suspected  urine,  and  stand  in  boiling  water  for  twenty 
minutes.  Then  place  in  cold  water.  On  cooling  yellow  radiat- 
ing groups  of  needle-shaped  crystals  of  phenyl-glucosazou  fall, 
which  may  be  detected  under  the  microscope. 

Bottger's  Test. — Add  to  a  couple  of  drachms  of  suspected 
urine  which  is  free  from  albumin  an  equal  volume  of  liquor 
potassse  and  a  few  grains  of  subnitrate  of  bismuth,  and  boil ; 
if  sugar  is  present,  it  will  reduce  the  salt  of  bismuth  to  black 
metallic  bismuth.  Substances  containing  sulphur,  like  albu- 
min, yield  a  similar  black  precipitate. 

The  Fermentation  Test. — Fill  a  four-ounce  bottle  three  parts 
full  of  urine,  and  add  a  fluid  drachm  of  ordinary  yeast,  or  a 
small  portion  of  compressed  yeast,  lightly  cork,  and  subject  to 
a  temperature  of  70°  to  80^  Fahr.  for  ten  or  twelve  hours. 
If  sugar  is  present,  fermentation  results  with  the  evolution  of 
carbon  dioxide,  and  the  specific  gravity  of  the  urine  falls. 

Quantitative  Tests. — Fermentation  test :  Employ  two  bottles 
of  urine,  and  to  the  one  add  the  yeast ;  at  the  end  of  twenty- 
four  hours  take. the  specific  gravity  of  each  specimen.  Every 
degree  lost  in  the  fermented  urine  indicates  a  grain  of  sugar 
to  the  fluidounce. 

FehUn(fs  Test. — To  one  cubic  centimetre  of  Fehling's  solu- 
tion add  four  cubic  centimetres  of  distilled  water,  and  boil ; 
if  the  solution  still  remains  clear,  add  jV  c-  c.  of  the  urine 
from  a  graduated  pipette,  and  gently  heat.  Continue  the  ad- 
dition of  the  urine,  little  by  little,  until  all  blue  color  has  dis- 


92  DISEASES    OF   THE   KIDNEYS. 

appeared.  If  one  cubic  centimetre  of  urine  has  been  added,  it 
will  have  contained  half  of  one  per  cent,  of  sugar.  If  two 
c.  c.  are  used,  it  will  have  contained  one-quarter  per  cent.  If 
but  a  half  of  a  cubic  centimetre  is  used,  it  will  have  contained 
one  per  cent. 

If  the  specific  gravity  indicates  that  the  amount  of  sugar  is 
great,  dilute  the  urine  with  a  definite  amount  of  water,  and 
estimate  accordingly  (Tyson). 

Albuminuria. — Albumin  in  the  urine. 

Its  Causes. — (1)  All  forms  of  nephritis.  (2)  Congestion  of 
the  kidney,  as  the  result  of  chronic  heart,  lung,  or  liver  dis- 
ease. (3)  Pregnancy.  (4)  Cyclical.  The  urine  may  be  albu- 
minous at  certain  times,  as  after  meals,  heavy  exercise,  bathing, 
or  on  rising  in  the  morning.  (5)  Accidental.  From  the  admix- 
ture of  albuminous  substances  with  the  urine,  as  pus,  semen, 
and  blood.  (6)  Certain  nervous  diseases,  as  epilepsy,  tetanus, 
and  injury  to  the  brain.  (7)  Extreme  ansemia.  (8)  Ingestion 
of  large  amounts  of  albuminous  food. 

Tests  for  Albumin.  Heller's  Test. — Pour  a  small  quantity  of 
colorless  nitric  acid  in  a  test>-tube,  and  allow  an  equal  c[uantity 
of  filtered  urine  to  trickle  from  a  pipette  down  the  sides  of  the 
tube  and  to  come  in  contact  with  the  acid.  If  albumin  is 
present,  a  sharply-defined  white  ring  is  formed  at  the  line  of 
junction. 

Turpentine,  copaiba,  and  other  oleoresins  eliminated  in  the 
urine  yield  similar  rings,  but  the  latter  are  redissolved  on  the 
addition  of  alcohol. 

Uric  acid  produces  an  undefined  pink  ring,  but  it  is  not 
exactly  at  the  line  of  contact,  and  is  redissolved  on  the  ap- 
plication of  heat. 
^  Johnson's  Test. — Fill  a  six-inch  test-tube  two-thirds  full  of 
filtered  urine,  and  allow  a  couple  of  drachms,  of  a  clear  satu- 
rated solution  of  picric  acid  to  flow  down  the  side  of  the  tube 
and  to  mix  with  the  urine.  Turbidity  indicates  the  presence 
of  albumin,  and  it  increases  on  gently  heating  the  tube  near  its 
mouth.  Certain  substances  in  the  urine,  like  the  alkaloids, 
produce  a  similar  turbidity,  but  this  disappears  on  the  appli- 
cation of  heat. 


THE   UEINE.  93 

Roberts's  Nitric  Magnesian  Test. — Very  delicate  and  reliable. 
The  test-fluid  is  made  by  adding  one  volume  of  strong  nitric 
acid  to  five  volumes  of  a  saturated  solution  of  sulphate  of 
magnesium,  and  is  employed  in  the  same  manner  as  nitric  acid 
in  Heller's  test. 

Acetonuria. — Acetone  results  from  the  metamorphosis  of 
albumin,  and  is  found  in  the  urine  in  many  conditions, 
notably  :  (1)  A  trace  in  normal  urine.  (2)  In  Cancer.  (3) 
Febrile  diseases.  (4)  Psychoses.  (5)  It  may  arise  as  a  primary 
condition  (Von  Jaksch).  (6)  In  diabetes  it  is  often  abundant. 
(7)  After  operations. 

LegaFs  Acetone  Test — To  four  c.c.  of  urine,  rendered  alkaline"" 
with  liquor  potassse,  add  a  few  drops  of  a  strong  solution  of  sodium 
nitro-prusside.  If  the  red  color  produced  turns  purple  on  the  ad- 
dition of  a  few  drops  of  concentrated  acetic  acid,  acetone  is  present. 

Diaceturia  and  Oxybuturia. — Diacetic  acid  and  oxy butyric 
acid  are  never  found  in  normal  urine,  but  are  found  associated 
with  acetone  in  certain  fevers,  and  especially  in  diabetes. 
Their  decomposition  yields  acetone,  and  they  are  probably  the 
cause  of  diabetic  coma. 

Test  for  Diacetic  Acid. — Boil  the  urine  and  add  a  solution 
of  ferric  chloride.  If  diacetic  acid  is  present,  a  Burgundy-red 
color  develops. 

Hsematuria. — Blood  in  the  urine. 

The  chief  causal  conditions  are :  (1)  Vicarious  menstrua- 
tion. (2)  Traumatism  applied  to  any  part  of  the  genito- 
urinary tract.  (3)  General  blood  dyscrasia,  as  in  the  specific 
fevers,  purpura,  malaria,  scurvy,  etc.  (4)  Congestion  of  the 
kidney  from  chronic  heart,  lung,  or  liver  disease.  (5)  Acute 
inflammation  of  any  part  of  the  genito-urinary  tract.  (6)  Stone 
in  the  genito-urinary  tract.  (7)  Varicose  veins  at  the  neck  of 
the  bladder.  (8)  It  may  occur  paroxysmally  without  obvious 
cause.  (8)  Parasites  in  the  genito-urinary  tract,  as  the  Filaria 
sanguinis  hominis,  and  the  Distoma  hgematobium. 

Diagnosis. — By  the  color  of  the  urine  and  by  microscopic 
and  spectroscopic  examination. 

Heller's  Test. — Boil  the    urine   with  a  solution   of  caustic\ 
potash,  and  phosphates  are  precipitated  which  assume  a  red 
color  from  the  freed  hsematin. 


94  DISEASES   OF   THE    KIDNEYS. 

Source  of  the  Hemorrhage.  Urethra. — The  urine  first  passed 
is  bloody,  and  the  other  symptoms  point  to  the  urethra. 

Bladder.  —  Bleeding  often  at  the  end  of  micturition,  and 
other  symptoms,  point  to  the  bladder. 

Kidney. — Blood  intimately  mixed.  There  may  be  blood- 
casts  or  clots,  and  the  other  symptoms  point  to  the  kidneys. 

HsBmoglobinuria. — Blood-pigment  in  the  urine. 

The  chief  causal  conditions  are:  (1)  Blood  disintegration 
from  the  specific  fevers,  scurvy,  purpura,  malaria,  etc.  (2) 
Absorption  of  internal  hemorrhagic  effusions.  (3)  It  follows 
transfusion  of  blood.    (4)  Paroxysmally,  without  obvious  cause. 

Indicanuria.  —  Indican   is  a  colorless   compound  resulting 

from  the  decomposition  of  albuminous  substances  in  the  small 

intestine,  and  by  oxidation  is  converted  into  indigo. 

.^      It  occurs  (1)  Frequently  in  health.     (2)  From  undue  reten- 

/  tion  of  material  in  the  small  intestine,  as  in  peritonitis,  intes- 

1    tiual  obstruction,  and  obstinate  constipation.     (3)  In  wasting 

\  diseases.     (4)  Purulent  inflammations.     (5)  Asiatic  cholera. 

Test  for  Indica7i.— Mix  equal  volumes  of  urine  and  fresh 
nitro-hydrochloric  acid,  and  add,  drop  by  drop,  a  fresh  con- 
centrated solution  of  chloride  of  lime.  Indican  is  indicated  by 
the  appearance  of  an  indigo-blue  color. 

Choluria. — Bile  in  the  urine.  Bile-pigment  is  found  in  the 
urine  in  all  forms  of  jaundice. 

Bile-acids  in  the  urine  indicate  hepatogenous  jaundice,  but 
their  absence  in  jaundice  is  no  proof  that  the  latter  is  hseraoto- 
genous  in  origin. 

Gmellin's  Test  for  Bile-pigment. — Allow  a  few  drops  of  lu'ine 
and  a  few  drops  of  fuming  nitric  acid  to  come  together  on  a 
white  plate.  If  bile  is  present,  there  will  be  an  iridescent  play 
of  colors — green,  blue,  violet,  and  red — at  the  line  of  contact. 

Pettenkoffer^ s  Test  for  Bile-acids. — Add  a  few  grains  of  cane- 
sugar  and  a  drop  of  sulphuric  acid  to  the  suspected  urine  in  a 
test-tube ;  heat  gently,  and  if  bile-acids  are  present  a  violet- 
red  color  is  produced. 

Chyluria. — Chyle  in  the  urine.  It  produces  a  milky  tur- 
bidity which  gradually  rises  to  the  top  of  the  urine  in  the  form 
of  pellicles  of  finely-divided  fat.  Its  chief  causes  are:  (1) 
Injufy  to  the  lymphatic  ducts.     (2)  Pregnancy.     (3)  Obstruc- 


RENAL    HYPEEiEMIA.  95 

tion  of  the  lymphatic  cliicts  by  the  Filaria  saugainis  homiuis, 
a  thread-worm  most  commonly  met  with  in  the  tropics. 

Pyuria. — Pus  in  the  urine.  It  results  (1)  from  suppura- 
tive inflammation  of  any  part  of  the  genito-urinary  tract,  and 
(2)  from  the  rupture  of  abscesses  into  the  tract. 

It  appears  as  a  dull,  greenish-yellow  precipitate  which  is 
couverted  into  a  clear  gelatinous  mass  by  the  addition  of  liquor 
potassEe.     It  can  always  be  detected  by  the  microscope. 

Source. — When  pus  is  from  the  kidney  it  is  intimately  mixed 
with  the  urine,  tlie  latter  has  an  acid  or  neutral  reaction,  and 
the  associated  symptoms  point  to  the  kidneys. 

When  the  pus  is  from  the  bladder  it  is  not  so  intimately 
mixed  with  the  urine ;  the  latter  is  usually  alkaline  in  reaction, 
and  the  associated  symptoms  point  to  the  bladder, 

REIVAI.  HYPERJEMIA. 

Varieties. — (1)  Active  hypersemia,  and  (2)  passive  hy- 
persemia. 

.   Active  Hypersemia. 

(Acute  Congestion.) 

Causes. — (1)  Exposure  to  cold  when  the  body  is  over- 
heated. (2)  Eruptive  fevers.  (3)  Poisons,  as  the  stimulating 
diuretics.     (4)  Pregnancy. 

The  same  cause  aggravated  would  produce  acute  nephritis. 

Pathology. — The  kidney  is  swollen,  of  a  deep  red  color, 
and  bleeds  freely  on  section.  Microscopic  examination  reveals 
cloudy  swelling  of  the  renal  epithelium. 

Symptoms, — Pain  over  the  loins.  The  urine  is  dark, 
scanty,  of  high  specific  gravity,  and  may  contain  a  trace  of 
albumin,  a  few  hyaline  casts,  and  some  free  blood. 

Prognosis. — If  the  cause  can  be  removed,  the  prognosis  is 
favorable. 

Treatment. — Absolute  rest.  Wet  cups  or  warm  fomenta- 
tions over  the  loins.  Liberal  use  of  water.  Saline  laxatives. 
Encourage  sweating  by  the  vapor  bath  or  small  doses  of  pilo- 
carpine. The  infusion  of  digitalis  may  be  used  to  increase  the 
quantity  of  urine.    • 


96  DISEASES   OF  THE   KIDNEYS. 

Passive  Hyperseinia. 

(Chronic  Congestion.) 

Etiology. — (1)  Causes  which  obstruct  the  general  ch-cula- 
tion,  as  chronic  heart,  lung,  and  liver  disease.  (2)  Pressure 
of  tumors  on  the  renal  veins.  (3)  Rarely  thrombosis  of  the 
renal  veins. 

Pathology. — The  kidney  is  swollen  and  of  a  bluish-red 
color,  and  later  becomes  hard  from  an  overgrowth  of  con- 
nective tissue  (cyanotic  induration).  In  advanced  cases  the 
renal  epithelium  is  fatty. 

Symptoms. — Sensation  of  weight  over  the  loins.  The  urine 
is  usually  diminished,  but  is  rarely  increased  in  quantity. 
Free  blood,  a  little  albumin,  and  occasionally  a  few  narrow 
hyaline  casts  are  found. 

Diagnosis. — The  comparative  absence  of  albumin  and 
casts,  the  absence  of  dropsy  and  ursemic  symptoms,  and  the 
presence  of  urea  in  normal  amount  will  separate  congestion 
from  nephritis. 

Prognosis.— Depends  on  the  cause. 

Treatment. — Rest.  Light  diet.  Dry  cups  to  the  loins. 
The  use  of  diuretics  when  the  urine  is  scanty.  The  following 
tonic  diuretic  pill  may  be  of  service  :— 

^   Quininse  sulph.,  gr.  xxx  ; 

Pulv.  digitalis,  gr.  xxx  ; 

Pulv.  scillse,  gr.  xxx ; 

Ext.  nucis  vomicee,  gr.  v  ; 

Pulv.  ferri  carb.,  gr.  xxx.— M      (Pepper.) 
Div.  in  pil.  ISTo.  xxx. 
Sig. — One  pill  every  three  hours. 

UREMIA. 

Definition. — The  name  applied  to  a  group  of  symptoms 
V  resulting  from  the  retention  of  toxic  materials  in  the  blood 
\  which  should  have  been  eliminated  by  the  kidneys. 

Symptoms. — It  may  develop  slowly  or  abruptly,  and  may 

manifest  any  of  the  following  phenomena:     Headache,  ver- 

.tigo,  delirium,  epileptiform  convulsions,  coma,  sudden  blind- 


ACUTE    NEPHRITIS.  97 

ness  (unassociated  with  any  retinal  change),  and  transienf 
paralysis  from  congestion  or  oedema  of  the  brain  or  cord. 

Pulmonary  Syinptonis. — Dyspnoea,  (ursemic  asthma),  Cheyne- 
Stokes  breathing. 

Abdominal  Symptoms. — Hiccough,  obstinate  vomiting,  and 
purging. 

General  Symjytoms. — The  skin  is  dry;  the  breath  has  a 
urinous  odor;  the  urine  is  scanty  and  deficient  in  urea.  The 
pulse  is  slow  and  full,  and^  the  temperature  subnormal;  but 
during  convulsions  the  temperature  may  rise  and  the  pulse 
become  rapid  and  feeble. 

Diagnosis. — The  various  manifestations  may  be  recognized 
as  ursemic  by  the  history,  the  temperature,  the  odor  of  the 
breath,  the  high  arterial  tension,  the  accentuated  second  sound 
of  the  heart,  the  presence  of  casts  and  albumin  in  the  urine, 
and  by  the  absence  of  any  other  cause. 

Prognosis. — Grave,  but  always  guarded,  for  recovery  is 
possible  after  tlie  most  serious  manifestations. 

Treatment. — Encourage  sweating  by  the  use  of  hot  air, 
or  vapor  baths.  Encourage  catharsis  by  the  use  of  croton  oil 
(one  drop  in  a  drachm  of  olive  oil),  elaterium  (gr.  ^),  or  a 
concentrated  solution  of  Epsom  salts. 

Relieve  renal  engorgement  by  digitalis  poultices,  or  dry 
or  wet  cups  to  the  loins.  When  the  patient  is  robust,  and 
the  pulse  is  strong,  venesection  will  be  of  paramount  impor- 
tance. If  the  pulse  is  very  weak,  alcohol,  strychnine,  digitalis, 
and  ammonia  may  be  required  hypodermically. 

In  convulsive  seizures,  in  addition  to  the  above  treatment, 
chloral  (gr.  xxx-xl)  may  be  given  by  the  rectum,  and  nitrite 
of  amyl  or  chloroform  by  inhalation. 

ACUTE  NEPHRITIS. 

(Acute  Bright' s  Disease,  Acute  Tubular  Nephritis,  Acute  Desqua- 
mative Nephritis,  Acute  Parenchyraatous  Nephritis,  Acute 
Catarrhal  Nephritis.) 

Definition. — An    acute   inflammatory  process   involving  "^ 
more  or  less  the  whole  kidney,  but  especially  affecting  the 
epithelium  of  the  tubules  and  glomeruli. 

7 


98  DISEASES   OF   THE    KIDNEYS. 

Etioi^ogy. — (1)  Exposure  to  cold  and  wet.  (2)  The  spe- 
cific fevers,  especially  scarlet  fever.  (3)  Poisous  which  are 
eliminated  through  the  kidneys,  as  cautliarides,  turpentine,  etc. 
(4)  Pregnancy. 

Pathology.^ — The  kidney  is  swollen  and  the  capsule  non- 
adherent.- At  first  the  organ  is  bright  red  in  color ;  it  soon, 
however,  becomes  pale  and  mottled  in  appearance,  although 
the  Malpighian  tufts  still  retain  their  deep  red  tint. 

Histology. — The  epithelium  of  the  tubules  and  glomeruli 
is  the  seat  of  cloudy  swelling  and,  later,  of  fatty  degeneration. 
Desquamated  epithelium,  blood-corpuscles,  and  an  albuminous 
exudate  block  up  the  tubules.  The  capillaries  are  dilated, 
their  walls  degenerated,  and  bloody  extravasations  are  not  in- 
frequently seen.  The  interstitial  tissue  is  more  or  less  infil- 
trated with  leucocytes. 

Symptoms. — Moderate  fever  and  its  associated  symptoms ; 
dull  lumbar  pain;  nausea  and  vomiting;  dropsy,  beginning 
in  the  face  and  becoming  general  ;  rapid  anaemia.  Uremic 
symptoms  may  develop  at  any  time. 

The  Urine. — Scanty  and  at  times  suppressed.  It  is  smoky 
in  appearance,  of  high  specific  gravity,  rich  in  albumin,  and 
throws  a  heavy  sediment,  which  contains  hyaline,  blood,  and 
epithelial  casts,  and  free  blood  and  epithelial  cells. 

Diagnosis. — As  the  general  syinptoms  are  often  slight,  the 

diagnosis   must  rest    on  the  examination  of  the  urine.     The 

-history,  and  the  absence  in  the  urine  of  wide,   highly  fatty 

casts,  will  serve  to  distinguish  acute  nejjhritis  trom  an  acute 

exacerbation  of  chronic  jjarenchymatous  nephritis. 

Peognosis. — Guardedly  favorable.  It  may  kill  by  exhaus- 
tion, uraemia,  or  dropsy.     It  may  become  chronic. 

Treatment. — Absolute  rest  in  bed  until  albumin  has  dis- 
appeared from  the  urine.  Milk  is  the  best  food  ;  but  butter- 
milk, gruels,  and  light  broths  are  admissible.  The  free  use  of 
Avater  should  be  encouraged.  Dry  or  wet  cups,  or  hot  fomen- 
tations should  be  applied  to  the  loins.  To  secure  vicarious 
(action  of  the  skin  vapor  baths  or  small  doses  of  pilocarpine 
(gr.  1^  to  Y^g)  may  be  employed.  Concentrated  saline  draughts, 
made  of  Rochelle  or  Epsom  salts,  may  be  given  to  secure 
watery  discharges  from  the  bowels.     Compound  jalap  powder 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  99 

(gr.  xx),  or  elaterium  (gr.  |)  may  be  substituted  for  the  saline. 
Stimulating  diuretics  should  be  avoided,  aud  diuresis  encour- 
aged by  alkaline  waters  and  infusion  of  digitalis.  Uraemia 
will  call  for  its  appropriate  treatment. 

Severe  cases  in  pregnancy  will  require  the  induction  of 
abortion  or  premature  labor. 

Marked  effusions  into  the  serous  cavities  will  sometimes 
demand  aspiration.  Convalescence  should  be  protracted,  and 
the  resulting  ansemia  will  call  for  some  preparation  of  iron, 
such  as  Basham's  mixture. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

(Chronic  Catarrhal  Nephritis,  Large   White  Kidney.) 

Etiology. — (1)  It  may  result  from  acute  nephritis.  (2)  It 
may  be  chronic  from  the  beginning.  Male  sex,  adult  life, 
frequent  exposure  to  cold  and  wet,  alcoholism,  congestion  from 
heart  disease,  aud  syphilis  are  predisposing  factors. 

Pathology. — In  the  first  stage  the  kidney  is  large  and 
pale-yellow  in  color ;  the  pallor  depends  on  anaemia  and  fatty 
degeneration  ;  the  tubes  are  filled  with  fatty  epithelium  and 
casts ;  there  is  always  some  overgrowth  of  the  interstitial  con- 
nective tissue. 

In  the  second  stage  the  organ  is  small,  pale  in  color,  its  sur- 
face rough,  and  its  capsule  somewhat  adhei'ent.  The  reduced 
size  depends  on  destruction  of  the  renal  epithelium  and  the 
contraction  of  the  overgrown  connective  tissue. 

Symptoms.  —  As  it  usually  begins  as  a  chronic  affection, 
the  following  symptoms  slowly  manifest  themselves :  Pro- 
gressive loss  of  flesh  and  strength  ;  marked  ansemia ;  gastro- 
intestinal disturbances ;  dropsy,  often  first  noted  in  the  face 
on  rising  in  the  morning ;  increased  arterial  tension ;  some 
hypertrophy  of  the  left  ventricle,  so  that  the  second  sound  at 
the  aortic  cartilage  is  accentuated.  Ursemic  symptoms  may 
develop  at  any  time. 

The  Urine. — Usually  diminished,  although  it  is  frequently 
normal  in  color  and  in  apjjearance.  It  is  highly  albuminous, 
and  throws  down  an  abundant  sediment,  which  contains  hya- 
line, fatty,  and  granular  casts,  and  fatty  epithelial  cells. 


100  DISEASES   OF   THE   KIDNEYS. 

Complications. — These  are  numerous  and  often  suggest 
the  diagnosis.  The  most  common  are  ursemia,  extensive 
dropsy  into  the  tissues  or  serous  cavities,  latent  inflammations 
of  the  serous  membranes,  valvular  heart  disease,  albuminuric 
retinitis,  apoplexy,  and  acute  exacerbations. 

Peognosis. — Unfavorable.  In  the  early  stages  recovery 
sometimes  results.  The  duration  is  from  a  few  months  to 
several  years. 

Treatment.  —  The  treatment  is  largely  dietetic  and 
hygienic.  Residence  in  a  dry,  warm,  and  equable  climate - 
may  prolong  life  or  eifect  a  cure.  Rest  is  an  essential  element 
in  the  treatment.  The  underclothing  should  be  woollen  or 
silk.  The  diet  should  be  non-nitrogenous,  and  in  severe  cases 
an  absolute  milk  diet  may  be  of  extreme  value.  The  bowels 
should  be  kept  active  by  natural  mineral  waters  or  saline 
laxatives.  When  the  urine  is  scanty,  digitalis,  caffeine,  or 
strontium  lactate  (gr.  xv-xxx)  may  prove  efficient.  Basham's 
mixture  may  be  employed  as  a  chalybeate  and  a  diuretic. 

In  excessive  dropsy  promote  catharsis  by  Epsom  salts  in 
concentrated  solution,  or  by  compound  jalap  powder;  and 
promote  diaphoresis  by  the  hot-air  bath,  or  by  pilocarpine. 

Niemeyer's  pill  (page  80)  or  the  following  combination  is 
often  very  efficient  in  troublesome  dropsy : — 

R    Spartein.  sulph., 

Caffein.  citrat.,  aa  gr.  xxx ; 

Lithii  benzoat.,  3j. — M. 
Ft.  chart.  No.  xii. 
8ig. — One  powder  every  three  hours. 

Acute  exacerbations  should  be  treated  as  primary  attacks  of 
acute  nephritis. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

(Red  Granular  Kidney,  Contracted  Kidney,  Gouty  Kidney.) 

Definition. — A  chronic  inflammatory  condition  of  the 
kidney  characterized  by  a  reduction  in  its  size,  due  to  an  over- 
growth and  subsequent  contraction  of  its  connective-tissue 
elements,  and  invariably  associated  with  general  arterial  scle- 
rosis and  cardiac  hypertrophy. 


CHRONIC   INTERSTITIAL  NEPHRITIS.  101 

Etiology. — It  may  be  secondary  to  parenchymatous 
nephritis,  or  result  from  the  passive  congestion  of  chronic 
heart  disease ;  but  generally  it  arises  as  a  primary  condition,- 
and  results  from  the  causes  which  predispose  to  sclerosis  in 
other  organs,  viz.,  middle  life,  male  sex,  syphilis,  the  gouty 
diathesis,  chronic  alcoholism,  and  chronic  mineral  poisoning, 
as  from  lead. 

Pathology. — The  kidneys  are  small,  and  red  in  color. 
The  surface  is  granular,  and  the  capsule  adherent.  The  or- 
gan is  firm,  cuts  with  difficulty,  and  on  section  often  reveals 
small  cysts  or  calcareous  deposits.  The  cortical  substance  is 
greatly  reduced  in  thickness.  Microscopic  examination  shows 
an  overgrowth  of  connective  tissue  which  has  contracted,  nar- 
rowed the  lumen  of  the  tubules,  and  interfered  with  the 
nutrition  of  the  epithelium,  and  as  a  result  the  latter  may 
show*  fatty  degeneration  with  desquamation.  The  arteries 
throughout  the  body  reveal  fatty  degeneration  of  the  media 
and  an  overgrowth  of  connective  tissue  in  the  intima  (arterio- 
sclerosis), and  from  the  resistance  thus  offered  hypertrophy  of 
the  heart  has  resulted. 

Symptoms. — A  slow  loss  of  flesh  and  strength  with  pro-  | 
gressive   anaemia.      Gastric   disturbances   are    very  common. 
The  arteries  are  rigid,  and  the  pulse  is  of  high  tension,  so  that 
the  second  sound  of  the  heart  is  accentuated  at  the  aortic  carti- 
lage. 

Palpitation  of  the  heart  is  often  noted.  Dyspnoea  is  a 
prominent  symptom,  and  may  result  from  heart-weakness, 
uraemia,  or  oedema  of  the  lungs.  Headache,  vertigo,  and 
insomnia  often  result  from  disturbed  circulation,  and  dimness 
of  vision  from  albuminuric  retinitis. 

Dropsy  is  often  absent,  or  is  slight  and  appears  late  in  the 
disease. 

The  urine :  Increased  in  quantity,  pale  in  color,  and  of  low 
specific  gravity  (1010—1005),  and  contains  but  a  trace  of  albu- 
min and  a  few  narrow  hyaline  casts. 

Complications.  —  Albuminuric  retinitis,  valvular  heart 
disease,  apoplexy  resulting  from  the  weakened  arteries  and 
large  heart,  uraemia,  latent  inflammations  of  serous  mem- 
branes, pneumonia,  and  bronchitis. 


102  DISEASES   OF  THE  KIDNEYS. 

Diagnosis. — The  arterial  changes,  casts  in  the  urine, 
ursemic  symptoms,"  and  the  absence  of  poikilocytosis  will  serve 
to  distinguish  chronic  nephritis  from  pernicious  ancemia. 

Chronic  parenchymatous  nephritis  usually  occurs  earlier  in 
life,  lacks  much  arterial  change,  produces  considerable  dropsy, 
and  urine  that  is  rich  in  albumin  and  tube-casts. 

Prognosis. — It  is  incurable,  but  may  last  many  years,  and 
under  favorable  conditions  comparative  comfort  may  be  ob- 
tained. 

Treatment. — The  dietetic  and  hygienic  treatment  is  the 
same  as  in  chronic  parenchymatous  nephritis.  Frequent  bath- 
ing with  friction  of  the  skin  should  be  encouraged,  and  the 
bowels  kept  regular  by  alkaline  waters. 

Absorbents,  like  the  bichloride  of  mercury  and  iodide  of 
potassium,  are  of  no  value.  If  the  stomach  will  bear  it,  iron 
will  be  of  service.  Digitalis,  caffeine,  and  strychnine  will  be 
very  useful  when  the  heart  weakens.  Nitroglycerin,  in  one 
minim  doses,  gradually  increased,  has  been  recommended  for 
the  high  arterial  tension. 

AMYLOID  KIDNEY. 

("Waxy  Kidney,  Lardaceous  BSdney.) 

Etiology. — (1)  Prolonged  suppuration,  particularly  in 
bone  disease.  (2)  Tuberculosis.  (3)  Syphilis.  (4)  Malarial 
cachexia. 

Pathology. — The  kidney  is  large  and  pale,  and  on  sec- 
tion presents  a  "  bacon-like"  appearance. 

Lugol's  solution  of  iodine  strikes  a  mahogany-red  color 
with  the  amyloid  material. 

On  microscopic  examination,  the  walls  of  the  bloodvessels, 
particularly  those  of  the  Malpighian  tufts,  are  found  thickened, 
and  infiltrated  with  a  homogeneous  wax-like  material,  which 
turns  red  when  treated  with  a  weak  solution  of  gentian-violet. 

Parenchymatous  and  interstitial  changes  are  always  noted, 
other  organs,  especially  the  liver  and  spleen,  are  similarly 
affected. 

Symptoms. — Loss  of  flesh  and  strength,  with  great  pallor 
and   moderate  dropsy.      Ursemic  symptoms  are  uncommon. 


EENAL    CALCULUS.  103 

The  liver  and  spleen  are  often  much  enlarged  from  the  same 
degeneration. 

The  Urine. — Usually  increased  in  amount,  pale  in  color,  and 
contains  considerable  albumin  and  wide  hyaline  and  granular 
casts. 

DrAdJsrosis. — The  history,  the  enlarged  liver  and  spleen, 
and  the  increased  amount  of  urine  containing  considerable 
albumin  suggest  the  diagnosis. 

Prognosis. — When  not  advanced,  and  the  cause  can  be 
removed,  the  disease  may  be  arrested.  As  a  rule,  the  i)rog- 
nosis  is  decidedly  unfavoral)le. 

Treatment. — The  primary  disease  will  claim  attention. 
In  bone  disease,  surgical  interference  may  be  requisite.  In 
syphilis,  iodide  of  potassium  and  mercurials  will  be  indicated. 
In  malarial  cachexia,  iron,  cpiiniue,  and  arsenic  should  be  em- 
ployed.    Tuberculosis  will  call  for  its  approjiriate  remedies. 

The  treatment  of  the  morbid  condition  is  hygienic  and 
dietetic.  Alterative  tonics,  like  the  iodide  of  iron,  may  prove 
beneficial  in  some  cases. 

RENAL  CALCULUS.  \ 

(Nephrolithiasis,  Renal  Gravel.) 

Definition.- — A  precipitated  urinary  concretion  found  in 
the  kidney. 

Etiology. — (1)  Male  sex.     (2)  Heredity.     (3)  Mal-assimi- 
lation.     (4)  Inflammation  of  the  pelvis  of  the  kidney.     Doubt- "^ 
less  mucus  or  desquamated  epithelium  forms  the  nucleus  upon 
which  the  stone  is  built. 

Varieties. — (1)  Uric  acid.  This  may  be  passed  as  sand, 
or  form  large  reddish-brown  stones  (2)  Oxalate  of  lime. 
This  forms  a  very  hard,  dark,  and  uneven  stone  (mulberry 
calculus).  (3)  Phosphates.  These  are  composed  of  phosphate 
of  lime,  and  ammonio-magnesium  phosphate,  and  are  soft, 
mortar-like  in  appearance,  and  are  often  deposited  on  other 
calculi.     (4)  Xanthine  and  cystine  are  rare  concretions. 

Events. — (1)  A  stoue  may  remain  latent  indefinitely.  (2)  It 
may  pass  out,  with  or  without  the  symptoms  of  colic.     (3)  It 


104  DISEASES   OP   THE   KIDNEYS. 

excites  pyelitis,  and  sometimes  abscess  of  the  kidney.  (4)  It 
may  obstruct  the  ureter  and  produce  hydro-neplirosis  or  pyo- 
nephrosis. (5)  It  may  excite  perinephritis,  and  may  perforate 
in  other  organs. 

Symptoms  of  Ren^l  Colic. — Sudden  onset,  with  sharp 
pain,  starting  in  the  back  and  radiating  down  the  ureter,  the 
penis,  testicle,  or  thigh.  There  may  be  retraction  of  the  testi- 
cle on  the  affected  side. 

The  symptoms  of  intense  pain  are  often  present,  viz : 
pallor,  cold  sweats,  weak  pulse,  and  reflex  vomiting. 

The  urine  subsequently  passed  may  contain  the  stone ;  or, 
as  a  result  of  irritation,  pus,  blood  and  desquamated  pelvic 
epithelium.  An  attack  may  last  from  a  few  moments  to 
several  hours. 

Diagnosis.  Biliary  and  Renal  Colic. — In  the  former  the 
pain  runs  from  the  right  hypochondriac  region  to  the  right 
shoulder;  there  is  often  jaundice,  and  the  urine  is  negative, 
while  the  stools  may  contain  the  stone. 

Prognosis. — In  view  of  the  complications  the  prognosis 
must  be  guarded. 

Treatment.  The  Attach. — Morphine  and  atropine  should 
be  employed  hypodermically,  and  warm  poultices  applied  to 
the  loins.  The  free  use  of  water  should  be  encouraged.  In 
severe  cases  chloroform  or  ether  may  be  inhaled  in  sufficient 
quantity  to  obtund  the  sensibility  of  the  patient. 

The  Interval. — When  symptoms  persist,  regulate  the  diet, 
and  put  the  patient  under  good  hygienic  conditions.  When 
the  reaction  of  the  urine  indicates  an  acid  stone,  the  salts  of 
lithium  or  the  vegetable  salts  of  potash  may  be  employed  in 
large  doses,  over  long  periods.  A  drachm  of  the  citrate  of 
potassium  or  five  to  ten  grains  of  the  carbonate  of  lithium 
may  be  given,  well  diluted,  several  times  a  day.  The  natural 
mineral  waters  are  of  some  value.  The  Buffalo  lithia  water 
may  be  employed  for  this  purpose,  and  its  palatableness  and 
efficiency  may  be  increased  by  the  addition  of  a  teaspoonful 
of  some  effervescing  preparation  of  lithium  to  each  potation. 

When  an  alkaline  stone  is  indicated,  benzoic  acid  or  boric 
acid  may  be  employed  in  a  similar  manner. 

In  severe  and  persistent  cases  the  stone  may  be  excised 


PYELITIS.  105 

(nephro-lithotomy) ;  and  if  the  operation  should  reveal  a 
badly-damaged  kidney,  its  removal  (nephrectomy)  would  be 
indicated. 

PYELITIS.  / 

(Pyelonephritis,  Pyonephrosis.) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney. 

Etiology. — (1)  It  may  result  from  stone  in  the  pelvis  of 
the  kidney  (calculous  pyelitis).  (2)  It  may  be  secondary  to 
urethritis  or  cystitis  extending  upwards  through  the  ureters. 
(3)  It  may  follow  pregnancy  or  the  specific  fevers.  (4)  Morbid 
growths,  such  as  tubercle  or  cancer.  (5)  Toxic  doses  of  the 
stimulating  diuretics  (copaiba,  cautharides,  etc.).  (6)  It  is 
rarely  idiopathic  from  exposure  to  cold  and  wet. 

Pathology. — The  mucous  membrane  is  swollen,  injected, 
and  covered  with  a  tenacious  secretion  composed  of  mucus, 
pus,  and  desquamated  epithelium.  Severe  cases  may  lead  to 
dilatation  of  the  pelvis,  Bright's  disease,  or  suppurative 
nephritis. 

Symptoms. — Moderate  fever  and  its  associated  phenomena. 
In  suppurative  nephritis  the  fever  may  be  irregular  and  asso- 
ciated with  hectic  or  typhoid  symptoms.  There  is  pain  and 
sometimes  tenderness  over  the  kidneys.  The  urine  is  turbid, 
acid  in  reaction,  and  on  standing  throws  down  a  sediment  con- 
taining considerable  mucus,  pus-corpuscles,  pelvic  epithelium, 
and  blood-corpuscles.  The  pus  and  blood  render  the  urine 
slightly  albuminous. 

Diagnosis. — The  absence  of  much  albumin,  of  tube-casts, 
and  dropsy  exclude  nephritis. 

Cystitis  may  be  excluded  by  the  absence  of  lumbar  pains 
and  of  acid  urine,  and  by  the  presence  of  frequeut  and  painful 
micturition  and  alkaline  urine  containing  vesical  epithelium. 

PerinepkritiG  abscess  is  also  associated  with  lumbar  pain 
and  hectic  fever ;  but  in  addition  there  is  often  oedema  over 
the  lumbar  region,  and  the  urine  may  be  normal. 

Sharp  pain  over  the  kidney,  increased  by  jarring  movements, 
and  reflected  down  the  ureters,  and  the  presence  of  much  blood 
in  the  urine  point  to  calculous  pyelitis. 


106  DISEASES    OF    THE    KIDNEYS. 

Tuberculous  pyelitis  may  be  recognized  by  the  history,  by 
the  presence  of  tubercle  in  other  organs,  and  by  tubercle  bacilli 
in  the  urine. 

Pyelitis  secondary  to  cystitis  is  recognized  by  the  history. 

Prognosis. — Depends  on  the  cause.  Mild  forms  resulting 
from  pregnancy,  specific  fevers,  or  exjjosure  to  cold,  usually 
recover  in  a  few  weeks.  The  tuberculous  and  suppurative 
varieties  are  unfavorable. 

Treatment. — Depends  on  the  cause.  Calculous,  pyelitis 
will  require  the  treatment  indicated  for  renal  calculus.  In 
simple  pyelitis  keep  the  patient  at  rest,  restrict  the  diet  to  light 
food,  preferably  to  milk,  ajiply  warm  poultices  locally,  use 
alkaline  diluents  and  some  sedative  mixture,  as  the  following : — 

^   Potass,  bromid., 

Sodii  bicarb.,  aa  gr.  clx  ; 
Ext.  belladonnfe,  gr.  iv; 
Ext.  buchu,  3j  ; 

Syr.  sarsp.  corap.,  q.  s.  ad  fsiv. — M.   (Pepper.) 
Sig. — Tablespoonful  three  times  a  day. 

In  pyelitis  following  cystitis,  treat  the  latter  locally,  and 
use  stimulating  diuretics,  like  eucalyptus,  sandalwood,  and 
copaiba. 

HYDROKEPHROSIS.  \ 

Definition. — Dilatation  of  the  pelvis  of  the  kidney,  wilh 
the  accumulation  of  a  watery  fluid,  resulting  from  obstruction. 

Etiology. — (1)  Congenital  stricture  of  the  ureter.  (2)  Im- 
paction of  a  calculus  in  the  ureter.  (3)  Abdominal  tumors 
compressing  the  ureter,  (4)  Tumors  growing  within  the 
urinary  passages.  (5)  An  inflammatory  stricture  of  the  ureter 
or  urethra. 

Pathology. — The  pelvis  reveals  all  grades  of  distention. 
In  extreme  cases  it  may  contain  several  quarts  of  fluid,  which 
is  at  first  urinous,  but  later  thin  and  watery.  There  is  more 
or  less  atrophy  of  the  renal  tissue. 

Symptoms. — Slight  distention  yields  no  symptoms.  In 
other  cases  a  tumor  slowly  develops  in  the  region  of  the 
afifected   kidney.      On    palpation  it   is   elastic,  and   perhaps 


FLOATING   KIDNEY.  107 

fluctuating ;  on  percussion,  dull ;  and  on  aspiration  it  yields  a 
clear  fluid,  which  usually  contains  urea  and  uric  acid. 

Diagnosis. — This  will  be  based  on  the  history,  the  exclu- 
sion of  other  abdominal  enlargements,  'and  the  chemical 
analysis  of  the  fluid  obtained  by  aspiration. 

Prognosis. — Usually  unfavorable.  When  it  is  unilateral, 
and  the  other  kidney  secretes  a  normal  amount  of  urine,  con- 
taining a  normal  amount  of  urea,  the  prognosis  is  guardedly 
favorable. 

Treatment. — When  the  distention  is  moderate  the  treat- 
ment is  expectant.  When  the  sac  is  large,  aspirate ;  and  if 
re-accuraulation  is  rapid,  establish  a  renal  fistula  or  remove 
the  organ. 

FLOATIT^^G  KIDNEY.   I 

(Movable  Kidney.) 

Definition. — A  distinctly  mobile  condition  of  the  kidney, 
dependent  upon  a  relaxation  of  the  tissues  which  surround  it. 

Etiology.— (1)  Female  sex.  (2)  Middle  life.  (3)  Rapid 
emaciation  leading  to  the  absorption  of  the  perinephritic  fat. 

(4)  A  congenital  relaxed  condition  of  the  perinephritic  tissues. 

(5)  Muscular  exertion,     (6)  Repeated  pregnancies. 
Symptoms.— The  right  kidney  is  the  one  usually  aifected, 

probably  from  its  relation  to  the  liver,  which  moves  during 
the  respiratory  acts.  The  kidney  may  be  found  in  any  part 
of  the  abdomen,  as  a  movable  tumor,  reniform  in  shape, 
somewhat  tender  to  the  touch,  and  rarely  imparting  the  pulsa- 
tion of  the  renal  artery. 

There  may  be  no  subjective  symptoms,  but  a  sense  of  un- 
easiness and  attacks  of  neuralgic  pain  are  often  noted.  At 
times  the  kidney  may  become  swollen  and  very  tender,  pro- 
bably from  twisting  of  the  renal  vessels  inducing  engorgement 
of  the  organ.  Emotional  disturbances  are  often  excited  by 
the  condition. 

Diagnosis. — The  reniform  shape  of  the  tumor,  its  free 
mobility,  its  stationary  size,  the  lessened  resistance  on  percus- 
sion over  the  renal  region  of  the  affected  side,  and  the  absence 


108  DISEASES   OF   THE   KIDNEYS. 

of  cachexia  will  serve  to  diagnose  a  floating  ]vidney  from  other 
abdominal  tumors. 

Treatment. — In  many  cases,  a  regulated  diet,  the  avoid- 
ance of  undue  exertion,  and  the  nse  of  a  broad  binder  applied 
firmly  to  the  abdomen  will  be  the  only  treatment  required. 
When  the  symptoms  persist  the  kidney  may  be  stitched  in 
its  normal  place  (nephrorrhaphy) ;  and  if  this  treatment  fails 
tlie  offending  organ  may  be  removed  (nephrectomy). 


DISEASES 

OF 

THE    BLOOD 


THE  BLOOD. 


In  health  the  blood  amounts  to  about  oue-thirteenth  of  the 
body-weight.  Xormal  blood  contains  approximately  5,000,000 
red  corpuscles,  and  from  5000  to  15,000  white  corpuscles  in 
the  cubic  millimetre,  the  ratio  of  the  latter  to  the  red  corpuscles 
being  variously  estimated  as  1  to  300  or  1  to  700. 

OLIGOCYTHJE3IIA. 

Oligocythaemia,  or  a  diminution  in  the  nnmber  of  red  corpus- 
cles, occurs  in  all  forms  of  anaemia,  but  is  especially  marked 
in  pernicious  anaemia,  where  the  number  may  fall  as  low  as 
400,000  to  the  cubic  millimetre. 

UEUCOCYTOSIS. 

Leucocytosis  is  a  temporary  increase  in  the  number  of  white 
blood-corpuscles.  It  occurs  physiologically  during  the  digestion 
of  proteids  and  fats,  after  massage,  after  cold  bathing,  and  in 
pregnancy;  and  pathologically  in  inflammatious  of  serous  mem- 
branes, in  certain  infections,  like  pneumonia,  diphtheria,  and 
erysipelas,  and  in  cancerous  cachexia. 

POIKILOCYTOSIS. 

Poikilocytosis,  or  a  condition  in  which  the  red  corpuscles 
.are  irregular  in  shape,  may  occur  in  any  form  of  severe  anae- 
mia, but  is  especially  marked  in  pernicious  anaemia. 

(109) 


110  DISEASES   OF   THE   BLOOD. 


d 

0 

b. 


/■ 


^®oO>^®.r-" 


IV^ 


B  o^c 


d 

Poikilo-,  macro-,  microcytosis  (as  represented  by  the  letters  d,  b,  c).  a,  normal  blood- 
eorimsclcs;  e,  product  of  decomposition  of  a  red  blood-corpuscle  ;  /,  nucleated  red  blood- 
corpuscle  (marked  aucemia). 

MICROCYTOSIS  AND  MACROCYTOSIS. 

Microcytosis  and  macrocytosis  are  conditions  in  which  the 
red  corpuscles  are  respectively  diminished  and  increased  in 
size.  They  may  occur  in  any  form  of  severe  anaemia,  but  are 
especially  marked  in  pernicious  anaemia. 

DUMLNISHED  HEMOGLOBIN. 

The  diminution  of  haemoglobin  is  usually  proportionate  to 
the  diminution  of  the  red  corpuscles,  but  there  are  two  marked 
exceptions,  namely,  in  chlorosis,  in  which  the  red  corpuscles 
may  be  diminished  only  twenty  or  thirty  per  cent.,  while  the 
haemoglobin  is  diminished  fifty  or  sixty  per  cent.,  and  in  per- 
nicious anaemia,  in  which  the  red  corpuscles  are  greatly  dimin- 
V  ished,  but  are  relatively  rich  in  haemoglobin. 

IVDELANEMIA. 

Melauaemia,  the  presence  in  the  blood  of  free  pigment,  usu- 
ally results  from  chronic  malarial  infection.     In  rare  instances 
it  has  been  found  associated  with  raelano-sarcoma  and  Addi- 
son's disease. 
\ 


ANAEMIA.  Ill 


LIPtEMIA. 


Lipsemia,  the  presence  in  the  blood  of  fine  drops  of  fatN 
may  be  noted  in  health.  It  is  also  observed  in  alcohol ism,y 
chyluria,  and  especially  in  diabetes. 

MICKOORGA^ISMS  IIV  THE  BLOOD. 

The  following  microorganisms  have  been  detected  in  the 
blood :  The  plasmodiiim  malaria,  the  filaria  sanguinis  hominis, 
the  distoma  haematobium,  the  spirillum  of  relapsing  fever, 
and  the  bacillus  of  anthrax,  glanders,  typhoid  fever,  and 
tuberculosis. 

ANEMIA. 

Definition. — A  condition  in  which  the  blood  is  diminished 
in  cpiantity,  or  is  deficient  in  one  or  more  of  its  constituents. 

Varieties. — (1)  Symptomatic  or  secondary  anaemia.  (2) 
Essential  or  primary  antemia. 

Symptoiiititic  Aiiseiuia. 

Etiology. — (1)  Congenital — ^a  constitutional  tendency.    (2)  \ 
Bad  hygiene — excesses,  faulty  diet,  impure  air,  lack'  of  sun- 
light.   (3)  Hemorrhage.    (4)  Organic  disease — cancer,  Bright's 
disease,  phthisis.     (5)  Toxic  agents — lead,  malaria,  syphilis. 

Pathology. — The  blood  is  deficient  in  lu^moglobin  and 
corpuscles,  and  the  tissues  show  fatty  degeneration. 

Symptoms.  General  Symptoms. — Pallor  of  skin  and  mucous 
membranes,  loss  of  flesh  and  strength,  and,  in  severe  cases, 
febrile  paroxysms  and  ecchymoses. 

Circulation. — A  full,  soft,  and  rapid  pulse,  pulsation  of  the 
cervical  vessels,  palpitation  of  the  heart,  hsemic  murmurs,  and 
slight  dropsy  beginning  in  the  feet. 

Respiration. — Hurried  breathing. 

Digestion  is  weak. 

Nervous  System. — Headache,  vertigo,  disturbed  sleep,  neu- 
ralgic pains,  and  a  tendency  to  syncope. 


112  DISEASES   OF   THE   BLOOD. 

Diagnosis. — Usually  evident,  but  appearances  are  decep- 
tive, and  an  absolute  diagnosis  rests  on  the  examination  of  the 
blood. 

Prognosis. — Depends  on  the  cause. 

Treatment. — Removal  of  the  cause,  when  possible.  Good 
hygiene.     The  use  of  iron,  arsenic,  and  general  tonics. 

Essential,  or  Priiuary  Aiiaeiuia. 

Definition. — Anaemia  not  dependent  upon  any  other  dis- 
ease, and  arising  without  obvious  cause. 

Varieties. — (1)  Pernicious  anaemia.     (2)  Chlorosis. 


PERNICIOUS  ANEMIA. 

(Idiopathic  Anaemia,  Progressive  Pernicious  Ancemia.) 

Definition. — A  grave  form  of  anaemia,  often  unassociated 
with  any  distinct  causal  lesions. 

Etiology. — In  many  cases  no  adequate .  cause  is  apparent. 
It  usually  appears  in  middle  life.  It  may  follow  parturition 
or  a  copious  hemorrhage.  It  is  sometimes  associated  with 
atrophy  of  the  gastric  tubules.  It  may  be  due  to  intestinal 
parasites  (anchylostoma  and  bothriocephalus). 

Pathology. — The  fat  is  very  yellow.  The  muscles  are 
deep  red.  The  organs  are  the  seat  of  fatty  degeneration.  The 
gastric  tubules  are  sometimes  atrophied.  An  excessive  amount 
-of  iron  pigment  is  found  in  the  liver  and  other  organs.  The 
bone-marrow  is  red  and  "  splenified."  Sclerosis  of  the  poste- 
rior columns  of  the  cord  is  sometimes  observed. 

According  to  one  theory,  the  disease  results  from  increased 
haemolysis  excited  by  poisons  absorbed  from  the  intestinal 
canal ;  according  to  another,  it  is  due  to  defective  haemogenesis. 

Symptoms. — Intense  anaemia  with  its  usual  symptoms ;  a 
lemon-yellow  tint  of  the  skin  ;  febrile  paroxysms  ;  increasing 
weakness  without  much  emaciation  ;  hemorrhages,  especially 
retinal ;   digestive  disturbance ;  and  urobilinuria. 

TJie  Blood. — The  red  corpuscles  are  extremely  reduced  in 
Xiumber,  sometimes  80  or  90  per  cent. ;  the  haemoglobin  is  dimiu- 


CHLOROSIS.  113 

islied,  but  not  proportionately  ;  the  red  corpuscles  are  of  various 
shapes  and  sizes,  some  small  (microcytes),  some  large  (macro- 
cytes),  some  very  large  and  nucleated  (gigautoblasts),  and  many 
irregular  in  outline  (poikilocytes).  The  number  of  white  cor- 
puscles is  not  materially  changed. 

Peognosis. — Very  unfavorable,  the  average  duration  being 
one  to  two  years.     Recovery  occasionally  occurs. 

Treatment. — Removal  of  any  obvious  cause.  Good  hy- 
gienic conditions  ;  a  nutritious  and  easilv  assimilable  diet ; 
rest ;  the  use  of  iron  and  arsenic,  especially  the  latter,  gradu- 
ally increased  to  its  physiological  limit. 

CHLOROSIS. 

(Green  Sickness,  Primary  Anaemia.) 

Etiology. — The  predisposing  causes  are  age  (puberty), 
sex  (females,  rarely  males),  and  bad  hygiene  (poor  food,  im- 
pure air,  overwork,  and  lack  of  sunlight).  The  absorption 
of  ptomaines  from  the  bowel  has  been  suggested  as  the  excit- 
ing cause. 

Pathology. — In  some  fatal  cases  imperfect  development 
of  the  circulatory  system  and  of  the  genitalia  has  been  ob- 
served. 

Symptoms. — Anaemia  with  its  usual  manifestations  ;  a  very 
marked  reduction  in  the  haemoglobin  without  a  corresponding 
reduction  in  the  number  of  red  blood-cells ;  a  greenish  tint  of 
the  skin;  a  capricious  appetite^^jjic'a) ;  constipation;  pallor  and 
weakness  without  loss  of  flesh  ;  aud  a  tendency  to  hysterical 
outbreaks  and  to  menstrual  disorders. 

Complications. — Gastric  ulcer,  dilatation  of  the  stomach, 
gastralgia,  amenorrhoea,  phthisis,  exophthalmic  goitre,  aud 
thrombosis. 

Prognosis. — Appropriate  treatment  is  followed  by  a  speedy 
recovery,  but  relapses  are  common. 

Treatment. — The  duration  of  the  disease  is  materially 
shortened  by  rest  and  the  regulation  of  the  diet.  The 
constipation  should  be  relieved  by  saline  laxatives.  The 
special  remedy  is  iron,  which  should  be  given  in  ascending 
doses. 


114  DISEASES   OF   THE   BLOOD. 

R    Ferri  sulphatis  ex., 

Potassii  carbon  atis,  aa  gr.  xl. — M. 
Ft.  in  pil.  No.  xx. 
Sig. — Three  pills  daily,  increased  to  nine  pills  daily. 

LEUCOCYTH^MIA. 

(Leucaemia.) 

Definition. — A  disease  characterized  by  a  great  excess  of 
the  white  corpuscles,  with  hyperplasia  of  the  spleen  or  of  the 
lymphatics,  or  changes  in  the  bone-marrow. 

Etiology. — The  causes  are  obscure.  Male  sex,  middle  life, 
malaria,  heredity,  bad  hygiene,  and  repeated  hemorrhages  are 
predisposing  factors.     It  is  probably  an  infectious  disease. 

Pathology. — Three  varieties  are  noted  :  (1)  Splenic  leu- 
caemia, in  which  the  spleen  is  enlarged  from  congestion  and 
hyperplasia.  (2)  Lymphatic  leucaemia,  in  which  the  lymphatic 
glands  are  the  seat  of  hyperplasia.  (3)  Myelogenic  leucaemia, 
in  which  the  medulla,  especially  of  the  ribs,  sternum,  and  verte- 
brae, is  converted  into  a  pulpy  material,  ranging  from  a  dirty 
yellow  to  a  deep  red  color,  according  as  the  congestion  or  the 
excess  of  leucocytes  predominates. 

Leucsemic  tumors  (collections  of  proliferated  leucocytes)  are 
frequently  found  in  the  various  organs.  The  liver  is  often 
\  considerably  enlarged.     The  tissues  show  fatty  degeneration. 

Symptoms. — The  general  manifestations  of  anaemia,  with  the 
following  special  symptoms  :  Enlargement  of  the  spleen,  liver, 
or  lymphatic  glands,  febrile  paroxysms  (101°-103°  F.),  hem- 
orrhage from  mucous  membranes,  digestive  disturbances,  dim- 
^  ness  of  vision  from  retinal  hemorrhage  or  leucaemic  deposits. 

The  Blood. — There  is  a  marked  increase  in  the  leucocytes. 
The  proportion  to  red  blood-corpuscles  may  be  1  to  50,  or 
V  even  1  to  10.  In  splenic  and  myelogenic  leucaemia  the  leuco- 
cytosis  results  from  an  increase  of  the  eosinophiles  and  from 
the  presence  of  myelocytes.*  In  lymphatic  leucaemia  the  in- 
crease is  in  the  lymphocytes.  Octahedral  crystals,  first  described 
by  Charcot,  are  found  on  blood-slides  which  have  been  kept  for 
some  time.  The  red  blood-corpuscles  are  somewhat  diminished 
in  number. 

*  Large  mononuclear  leucocytes  containing  fine  neutrophilic  granules. 
They  are  not  found  in  normal  blood. 


PSEUDO-LEUC^MIA ADDISON'S   DISEASE.  115 

Prognosis. — Recovery  rarely  follows.  Death  usually  results 
in  from  one  to  three  years.  Tonics,  such  as  iron,  quinine,  and 
arsenic,  should  be  tried.  Removal  of  the  spleen  has  given 
negative  results. 

PSEUDO-LEUC^MTA. 

(Hodgkins'  Disease,  Lymphatic  Anaemia,  Malignant  Lymphoma.) 

Definition. — A  disease  characterized  by  a  hyperplasia  of 
the  lymphatic  structures  and  by  progressive  anaemia,  without 
a  marked  increase  of  the  white  corpuscles. 

Etiology. — The  causes  are  obscure.  Male  sex,  early  life, 
and  simple  adenitis  seem  to  be  predisposing  causes.  It  is  prob- 
ably of  infectious  origin. 

Pathology. — There  is  hyperplasia  of  the  lymphatic  struc- 
tures ;  glands,  spleen,  and  bone-marrow  sharing  in  the  process. 
New  foci  of  lymphatic  tissue  are  often  noted. 

Symptoms. — The  general  manifestations  of  ansemia,  with ' 
the  following  peculiar  symptoms :  Enlargement  of  the  lym- 
phatic glands,  which  usually  begins  in  the  neck ;  the  glands 
are  painless  and  at  first  distinct  and  freely  movable,  but  later 
they  fuse  and  form  firm  nodular  masses.  The  spleen  is  gen- 
erally somewhat  enlarged.     Febrile  paroxysms  are  common. 

Diagnosis. — Tuberculous  adenitis  may  resemble  pseudo- 
leucsemia,  but  the  former  is  more  common  in  children,  is  more 
apt  to  aifect  the  submaxillary  glands,  and  is  generally  followed 
by  caseation  and  suppuration  of  the  glands. 

Prognosis. — Very  u  nf a vorable. 

Treatment. — The  same  as  for  leucaemia. 

ADDISON'S  DISEASE. 

Definition. — A  constitutional  disease,  characterized  ana- 
tomically by  a  degeneration  of  the  suprarenal  capsules  or 
semilunar  ganglia,  and  clinically  by  pigmentation  of  the  skin, 
ansemia,  and  prostration. 

Etiology. — Male  sex,  middle  life,  and  laborious  work  are 
predisposing  factors. 

Pathology. — In  most  instances  tuberculosis  of  the  supra- 


116  DISEASES   OF    THE   BLOOD. 

reual  capsules  is  discovered.  Other  affections,  such  as  tumors 
and  degeneration  of  the  suprarenal  capsules,  may  produce  the 
disease.  lu  a  few  instances  degenerative  changes  in  the 
abdominal  sympathetic  ganglia  have  been  the  only  discoverable 
lesions. 

Symptoms. — Moderate  anaemia,  with  bronzing  of  the  skin 
and  mucous  membranes,  great  weakness,  and  gastric  irritability 
are  its  chief  manifestations. 

Prognosis. — The  disease  has  been  considered  incurable, 
death  generally  resulting  in  from  one  to  two  years ;  but 
recently  good  results  have  followed  the  ingestion  of  supra- 
renal glands. 

Treatment. — The  general  treatment  includes  rest,  a  nutri- 
tious but  easily  assimilable  diet,  and  the  use  of  tonics  like  iron, 
arsenic,  quinine,  and  strychnine.     A  glycerine  extract  of  two 

f  fresh  suprarenal  capsules,  or  an  equivalent  amount  of  dried 

I      extract,  should  be  taken  daily. 

HEMOPHILIA. 

(Bleeder's  Disease,  Hemorrhagic  Diathesis.) 

Definition. — An  hereditary  disease,  characterized  by  a 
tendency  to  bleed  excessively  from  slight  wounds,  or  even 
spontaneously. 

Etiology. — The  great  cause  is  heredity.  It  is  more  com- 
mon in  males,  but  is  usually  transmitted  by  females,  even  by 
those  who  are  not  themselves  afflicted. 

Pathology. — Unknown.  In  some  instances  the  arteries 
have  been  found  smaller  than  normal,  with  their  walls  thin 
and  degenerated. 

Symptoms.  —  The  chief  symptom  is  free  and  persistent 
bleeding  after  trivial  injury.  Spontaneous  hemorrhages  from 
mucous  membranes  of  the  nose,  stomach,  bowel,  etc.,  and  sub- 
cutaneous extravasations  are  quite  common.  The  only  other 
symptom  is  a  peculiar  inflammation  of  the  joints,  resembling 
rheumatism. 

Prognosis. — ^Unfavorable.  Grandidier  states  that  one-half 
die  before  the  eighth  year,  and  less  than  one-eighth  survive 
their  tvveuty-iirst.     In  some  instances  the  tendency  is  outgrown. 


SCURVY — PURPURA   HEMORRHAGHCA,  117 

Treatment. — Protective  and  palliative.  The  bleeding  will 
demand  the  application  of  cold  compresses  and  styptics,  and 
the  internal  nse  of  haemostatics  like  ergot,  hamamelis,  or  erig- 
eron.     The  resulting  ansemia  will  be  benefited  by  iron. 

SCURVY. 

(Scorbutus.) 

Etiology. — Lack  of  fresh  vegetables  and  bad  hygienic 
surroundings  are  the  predisposing  causes. 

Pathoi-OGY.  —  The  pathogenesis  of  scurvy  is  unknown. 
Fatty  degeneration  from  the  anaemia,  and  widespread  ecchy- 
moses  are  found  after  death. 

Symptoms. — The  general  manifestations  of  anaemia,  with 
great  weakness ;  spongy,  bleeding  gums,  fetor  of  the  breath, 
and  loosening  of  the  teeth  ;  subcutaneous  ecchymoses,  and 
hemorrhages  from  the  mucous  membranes  ;  and  finally,  a  pain- 
ful, brawny  induration  of  the  muscles  due  to  a  sanguineous 
exudation. 

An  infantile  form  of  scurvy  [Barlow's  Disease)  sometimes 
follows  the  prolonged  use  of  condensed  milk,  sterilized  milk,  or 
proprietary  foods.     The  characteristic  symptoms  are :  Asthe-\ 
nia,  anaemia,  immobility  of  the  legs,  pseudo-paralysis,  extreme    ^ 
tenderness,  swelling  without  pitting,  thickening  of  the  bones 
from  subperiosteal  hemorrhage,  ecchymoses,  occasionally  spongy     / 
gums,  and  a  tendency  to  epiphyseal  fractures.  / 

Prognosis. — Favorable  in  its  earlier  stages. 

Treatment. — Fresh  vegetables  and  the  free  use  of  leraon-\ 
juice.    Iron  in  moderate  doses.    Weak  solutions  of  chlorate  of  j 
potassium  or  nitrate  of  silver  may  be  applied  to  the  bleeding 
gums.    In  infantile  scurvy  good  results  follow  the  use  of  fresh 
milk,  beef-juice,  and  orange-juice. 

PURPURA  HEMORRHAGICA. 

(Morbus  Maculosus  Werlhofii.) 


Definition. — A  condition  arising  without  obvious  cause, 
and  characterized  by  extravasation  of  blood  in  the  skin  and 
bleeding  from  the  raucous  membranes. 


\ 


118  DISEASES   OF   THE   BLOOD. 

Etiology. — Bad  hygiene,  early  life,  and  female  sex  exert 
some  predisposing  influence ;  but  it  may  occur  at  any  age  and 
in  the  most  robust  of  either  sex.  A  microorganismal  cause  has 
been  suggested. 

Pathology. — Unknown. 

Symptojis.  —  The  onset  may  be  marked  by  some  fever, 
headache,  malaise,  and  pain  in  the  limbs ;  but  these  symptoms 
may  be  absent,  and  the  disease  ushered  in  with  a  copious  crop 
of  small  hemorrhages  into  the  skin,  followed  by  bleeding  from 
the  mucous  membranes.  Anaemia  and  its  associated  phenomena 
develop  in  severe  cases. 

Diagnosis. — The  absence  of  high  fever  and  nervous  symp- 
toms will  separate  it  from  typhus  fever  and  cerehro-sp'mal 
meningitis.  The  history  and  the  absence  of  spongy  gums  and 
of  brawny  induration  of  the  muscles  will  separate  it  from 
scurvy.  Previous  health  and  the  absence  of  hereditary  ten- 
dency separate  it  from  hcemophilia. 

Prognosis. — Depends  on  the  severity.  Mild  cases  recover 
in  from  one  to  two  weeks ;  severe  cases  may  prove  fatal  in  a 
few  days  from  exhaustion  or  hemorrhage  into  the  brain.  Re- 
lapses are  common. 

Teeat:\iext.  —  Rest.  Light,  nutritious  food.  Arsenic, 
iron,  turpentine,  and  the  fluid  extract  of  hamamelis  are  the 
most  serviceable  remedies. 


DISEASES 


CIRCULATORY  SYSTEM. 


INSPECTION. 

Inspection  detects  the  apex-beat,  and  determines  its  position, 
force,  and  extent ;  any  abnormal  centres  of  pulsation  ;  and  any 
unnatural  prominence  over  the  precordial  region. 

The  Apex-beat. 

The  normal  position  of  the  apex -beat  is  in  the  fifth  inter- 
costal space,  about  an  inch  within  the  mammary  line  (a  line 
drawn  from  the  middle  of  the  clavicle  parallel  with  the 
sternum).  The  beat  is  usually  detected  by  inspection  or  pal- 
pation, but  when  these  methods  fail  it  may  be  localized  by 
auscultation,  the  point  in  the  region  of  the  apex  where  the 
first  sound  is  heard  with  maximum  intensity  corresponding 
to  the  beat. 

The  Effect  of  Respiration  and  Position  on  the  A])ex-beat.— 
The  location  and  force  of  the  apex-beat  are  modified  by  the 
posture  of  the  patient  and  the  stage  of  the  respiratory  act.  In 
the  recumbent  position  the  apex-beat  may  be  elevated  an  inch 
or  more,  and  when  the  body  is  inclined  to  the  left,  the  heart 
being  a  more  or  less  movable  organ,  the  beat  may  be  detected 
in  the  mammary  line,  or  even  some  distance  to  its  outer  side. 

During  forced  inspiration  the  beat  may  become  imper- 
ceptible, or  if  such  is  not  the  case  it  may  be  found  some 
distance  below  its   usual    place,  on  account  of  the   upward 

(119) 


120  DISEASES   OF   THE   (JIRCULATORY   SYSTEM. 

movement  of  the  ribs  in  the  inspiratory  act.  During  forced 
expiration,  the  air  being  driven  from  the  Inng-tissuc  in  front 
of  the  heart,  the  beat  becomes  more  forcible,  and  its  position 
elevated  on  account  of  the  descent  of  the  ribs  which  occurs  in 
expiration. 

In  view  of  the  influence  exerted  by  respiration  and  position 
on  the  apex-beat  the  patient,  as  a  rule,  should  be  examined  in 
the  erect  or  sitting  posture,  while  breathing  quietly. 

Displacement  of  the  Apex-beat. 

Displacement  to  the  left  may  result  from  : — 

1.  Hypertrophy  and  dilatation  of  the  heart  (down  and  to 
the  left.) 

2.  Pericardial  effusion  (up  and  to  the  left). 

3.  Chronic  diseases  of  the  left  lung  and  pleura,  associated 
wath  retraction — as  fibroid  phthisis  and  pleural  adhesions. 

4.  Abdominal  tumors  and  effusions  (up  and  to  the  left). 

5.  The  pressure  of  a  pleural  effusion  on  the  right  side  (up 
and  to  the  left). 

Displacement  to  the  right  may  be  caused  by  : — 

1.  Chronic  disease  of  the  right  lung  or  pleura  associated  with 
retraction. 

2.  Pressure  of  a  pleural  effusion  on  the  left  side. 
Displacement  doiomvard  may  result  from  : — 

1.  Hypertrophy  and  dilatation  of  the  heart,  chiefly  the  left 
ventricle. 

2.  Pressure  of  solid  growths  in  the  upper  mediastinum. 

3.  Aneurism  of  the  aortic  arch. 

4.  Enlargement  of  the  liver,  causing  traction  through  the 
central  tendon  of  the  diaphragm.     (Paul.) 

Deformity  of  the  chest  may  cause  displacement  in  any 
direction. 


Changes  in  Force  and  Extent  of  the  Apex-heat. 

The  force  and  extent  may  he  increased  by  : — 
1.  Hypertrophy  of  the  heart. 


mSPECTION.  121 

2.  Excited  action  of  the  heart,  from  drugs,  reflex  iri'itation, 
excitement,  or  diseases,  as  exophthalmic  goitre. 

3.  Shrinking  of  the  lungs,  as  in  phthisis. 
A  weak  apex-beat  may  be  noted  in  : — 

1.  Healthy  people. 

2.  Defeneration  or  dilatation  of  the  heart. 

3.  Pericardial  effusion. 

4.  Emphysema. 

5.  Shock  or  collapse. 

Abnormal  Centres  of  Pulsation. 

Epigastric  jntlsation  may  result  from  : — 

1.  Excited  action  of  the  heart  from  any  cause. 

2.  Enlargement  of  the  right  ventricle. 

3.  A  pulsating  aorta  noted  in  certain  nervous  and  anremic 
patients. 

4.  Aortic  aneurism. 

5.  Tumors  of  the  left  lobe  of  the  liver  resting  on  the  aorta. 
Puhation  at  the  base  of  the  heart  may  result  from  : — 

1.  Aneurism  of  the  aortic  arch. 

2.  Cardiac  hypertrophy. 

3.  Shrinking  of  the  lungs,  as  in  phthisis. 

Pulsation  in  the  left  axillary  region  may  result  from  : — 

1.  Enlargement  of  the  heart. 

2.  A  tense  purulent  effusion  in  the  left  pleural  sac  (pulsat- 
ing empyema). 

3.  Aneurism. 

4.  Chronic  diseases  of  the  left  lung  and  pleura,  associated 
with  retraction. 

Unnatural  j)ulsation  in  the  carotids  may  result  from  : — 

1.  Excitement  of  the  heart  from  any  cause. 

2.  Exophthalmic  goitre. 

3.  Ansemia. 

4.  Valvular  disease,  especially  aortic  regurgitation. 

5.  Aneurism  or  dilatation  of  the  vessels. 

6.  Unnatural  elasticity  of  the  vessels,  noted  in  certain  ner- 
vous and  anaemic  patients. 


122  i)iSl5ASES   OP   THE   CIRCULATORY   SYSTEM. 

Jugular  Pulsation. 

The  jugular  vein  often  becomes  distended  in  forced  expira- 
tion and  coughing.  Distention  of  the  jugular  vein  is  some- 
times noted  in  adherent  pericardium. 

A  true,  rhythmical  venous  pulsation  usually  results  from 
tricuspid  regurgitation. 

A  pulsation  may  be  transmitted  to  the  jugular  vein  from  the 
underlying  carotid,  but  this  false  pulsation  will  still  continue 
when  light  pressure  is  made  on  the  vein  at  the  root  of  the 
neck,  while  the  true  venous  pulse  will  cease. 

Prsecorclial  Prominence. 

Unnatural  promiyience  of  the  prcecordia  may  result  from  : — 

1.  Deformity. 

2.  Enlargement  of  the  heart. 

3.  Pericardial  effusion. 


PALPATION. 

This  not  only  determines  the  position,  force,  extent,  and 
rhythm  of  the  apex-beat,  but  also  detects  the  existence  of  any 
fremitus  or  thrill. 

A  thrill  is  a  vibratory  sensation  likened  to  that  received 
when  the  hand  is  placed  on  the  back  of  a  purring  cat.  Thrills 
at  the  base  of  the  heart  may  result  from  valvular  lesions,  athe- 
roma of  the  aorta,  aneurism,  and  from  roughened  pericardial 
surfaces,  as  in  pericarditis. 

A  presystolic  thrill  at  the  apex  is  almost  pathognomonic  of 
mitral  stenosis. 

PERCUSSIO:^. 

This  determines  the  shape  and  extent  of  the  cardiac  dulness. 

The  normal  area  of  superficial  or  absolute  percussion-dulness 
(the  part  uncovered  by  lung)  is  detected  by  light  percussion, 
and  extends  from  the  fourth  left  costo-sternal  junction  to  the 


AtJSCtTLTATIOJJ.  123 

apex-beat ;  from  the  apex-beat  to  the  junction  of  the  xiphoid 
cartilage  with  the  sternum  and  thence  up  the  left  border  of 
the  sternum. 

The  normal  area  of  deep  percussion-dulness  (the  heart  pro- 
jected on  the  chest-wall)  is  detected  by  firm  percussion,  and 
extends  from  the  third  left  costo-sternal  articulation  to  the 
apex-beat;  from  the  apex-beat  to  the  junction  of  the  xiphoid 
cartilage  with  the  sternum ;  and  thence  up  the  right  border  of 
the  sternum  to  the  third  rib.  The  lower  level  of  the  cardiac  dul- 
ness  fuses  with  the  liver  dulness,  and  can  rarely  be  determined. 

The  area  of  cardiao  duhiess  is  increased  in  :  (1)  Hypertrophy 
and  dilatation  of  the  heart.  (2)  Pericardial  effusion.  It  is 
apparently  increased  in  shrinking  of  the  lungs,  as  in  phthisis. 

The  area  of  cardiac  dulness  is  diminished  in  :  (1)  Emphy- 
sema. (2)  Pneumothorax.  (3)  Pneumopericardium  (rare). 
(4)  Gaseous  distention  of  the  stomach. 

AUSCULTATION. 

This  determines  the  quality,  intensity,  and  rhythm  of  the 
heart-sounds,  and  detects  the  presence  of  any  adventitious 
sounds,  as  murmurs.  The  two  sounds  heard  over  the  heart  have 
been  represented  by  the  syllables,  "  lubb,  tup."  The  first  sound 
(systolic)  results  from*  contraction  of  the  ventricle,  tension  of 
the  auriculo-ventricular  valves,  and  the  impact  of  the  heart 
against  the  chest-wall,  and  is  synchronous  with  the  apex-beat 
and  carotid  pulse.  This  sound  is  prolonged  and  dull.  After 
the  first  sound  there  is  a  short  pause,  and  then  follows  the 
second  sound  (diastolic),  which  results  from  the  closure  of  the 
aortic  and  pulmonary  valves.  This  sound  is  short  and  high- 
pitched.  After  the  second  sound  a  longer  pause  follows  be- 
fore the  first  is  again  heard. 

The  Intensity  of  the  Heart-sounds. 

Both  sounds  are  accentuated  in  :  (1)  Excitement  of  the  heart 
from  any  cause.  (2)  Anaemia.  (3)  Cardiac  hypertrophy. 
(4)  Subjects  with  thin  chest- walls.  (5)  Consolidation  of  the 
lung,  as  in  phthisis  and  pneumonia. 


124  DISEASES    OF   THE   CIRCULATORY    SYSTEM. 

Aecentuation  of  the  aortic  second  sound  results  from  :  (1)  Hy- 
pertrophy of  the  left  ventricle.  (2)  High  arterial  teusion,  as 
in  arterio-sclerosis  and  Bright's  disease.     (3)  Aortic  aneurism. 

Accentuation  of  the  pulmonary  second  sound  results  from  : 

(1)  Pulmonary  obstruction,  as  in  emphysema,  pneumonia,  and 
the  congestion  of  the  lungs  following  mitral  disease.  (2)  Hy- 
pertrophy of  the  right  ventricle. 

Weakness  of  both  sounds  is  noted  in  :    (1)  General  obesity. 

(2)  General  debility.  (3)  Degeneration  or  dilatation  of  the 
heart.     (4)  Pericardial  or  pleural  effusion.     (5)  Emphysema. 

Reduplication  of  the  Heart-sounds. 

This  is  probably  due  to  a  lack  of  synchronous  action  in  the 
valves  of  the  two  sides  of  the  heart,  and  results  from  many  con- 
ditions, but  notably  from  increased  resistance  in  the  systemic 
or  the  pulmonary  circulation,  as  in  arterio-sclerosis  of  chronic 
nephritis  and  in  emphysema.  It  is  frequently  noted  in  mitral 
stenosis  and  pericarditis. 

Adventitious  Sounds  or  Murniiu'S. 

A  murmur  is  an  abnormal  sound  heard  over  the  heart  or 
bloodvessels,  and  may  result  from  :  (1)  Obstruction  or  regur- 
gitation at  the  valves  following  endocarditis.  (2)  Dilatation 
of  the  ventricle  or  relaxation  of  its  walls,  rendering  the  valves 
relatively  insufficient.  (3)  Aneurism.  (4)  A  change  in  the 
blood  constituents,  as  in  anaemia.  (5)  Eoughening  of  the 
pericardial  surfaces,  as  in  pericarditis.  (6)  Irregular  action 
of  the  heart. 

Murmurs  produced  within  the  heart  are  termed  endocardial ; 
those  produced  outside,  exocardial ;  those  producecl  ^iii  aneu- 
risms, bruits;  and  those  produced  by  anaemia,  hsemic  miirmurs. 

Hsemic  Murmurs. 

Hajmic  murmurs  have  the  following  characteristics  :  They 
are  soft  and  blowing  in  character,  usually  systolic  in  time, 
heard  best  over  the  "pulmonary  valves,  transmitted  into  the 


THE    PULSE.  125 

carotids,  accompanied  with  a  hum  in  the  veins  of  the  neck, 
associated  with  the  symptoms  of  ausemia,  and  disa^jpear  with 
the  latter. 

Pericardial  Friction- sounds. 

Pericardial  murmurs,  or  friction-sounds,  are  superficial, 
rough  and  creaking  in  quality,  to  and  fro  in  time,  not  trans- 
mitted beyond  the  prsecordia,  and  may  be  modified  by  pressure 
of  the  stethoscope. 

The  Aneiu'isnial  Mnrniiu*,  or  Brviit. 

This  is  usually  loud  and  booming  in  character,  systolic  in 
time,  heard  best  over  the  aorta  or  base  of  the  heart,  and  is 
often  associated  with  an  abnormal  area  of  dulness  and  pulsa- 
tion, and  with  symptoms  resulting  from  jjressure  on  neighbor- 


ing structures. 


THE  PULSE. 


The  average  frequency  of  the  pulse  in  the  adult  is  between 
70  and  80  per  minute  At  birth  it  is  between  130  aud  150; 
in  the  second  year  about  100,  and  so  it  gradually  lessens  as 
the  child  grows  old. 

Increased  frequency  of  the  Pulse  {Tachycardia). 

Habitual  frequency  is  sometimes  noted  in  health.  The 
frequency  may  be  temporarily  increased  by  erect  posture,  ex- 
citement, eating,  and  the  use  of  stimulants. 

Abnormal  frequency  may  result  from — (1)  Pyrexia.  The 
pulse  usually  bears  a  definite  relation  to  the  temperature,  but 
in  certain  diseases,  as  scarlet  fever  and  septicaemia,  it  is  dispro- 
portionately rapid.  (2)  Exophthalmic  goitre.  (3)  Organic 
heart-disease.  (4)  Pressure  at  the  base  of  the  brain  sufficient  to^ 
paralyze  the  pneumogastrics,  as  in  clot,  tumor,  and  advanced 
meningitis.  (5)  Shock.  (6)  Reflex  irritation,  as  in  dyspepsia, 
ovarian,  or  uterine  disease.  (7)  An  independent  paroxysmal 
neurosis  ("  Essential  Paroxysmal  Tachycardia").  (8)  Certain  J 
drugs — belladonna,  nitrites,  alcohol,  etc.  (9)  Eheumatoid  ar- 
thritis (Sansom). 


126 


DISEASES   OF   THE    CIRCULATORY   SYSTEM. 


Infrequency  of  the  Pulse  {Bradycardid). 

Physiological  slowness  is  noted  in  repose,  fasting,  tlie  puer- 
periura,  old  age,  and  habitually  in  certain  people  (40  to  60  per 
minute). 

Pathological  infrequency  is  observed  in  many  conditions, 
notably — (1)  In  organic  heart  disease,  especially  fatty  degen- 
eration and  fibroid  induration.  (2)  In  jaundice.  (3)  From 
pressure  at  the  base  of  brain  sufficient  to  irritate  the  vagus, 
as  in  beginning  meningitis.  (4)  At  the  close  of  febrile  dis- 
eases, as  typhoid  fever,  pneumonia,  etc.  (5)  After  the  use  of 
certain  drugs,  as  digitalis,  aconite,  opium,  etc. 

Irregvilar  Rhythm. 

(Arhythmia.) 

The  Intermittent  Pulse. — This  per  se  is  not  significant  of 
any  pathological  condition.  It  is  habitually  noted  in  certain 
people,  after  exercise,  eating,  excitement,  or  the  use  of  tobacco, 
tea,  or  coffee.  It  is  frequently  reflex  from  gastric,  hepatic, 
uterine,  or  renal  disease.  It  is  common  in  lithsemia  and  fatty 
degeneration  of  the  heart. 
/  There  may  be  a  false  intermission  or  infrequency  in  the 
■  radial  pulse  when  the  heart  fails  to  transmit  all  its  beats  to 
the  wrist.    This  condition  is  usually  indicative  of  a  weak  heart. 

The  Irregular  Pulse. — This  has  the  same  significance  as  the 
intermittent  pulse.  It  is  also  very  common  in  myocarditis 
and  valvular  disease,  especially  mitral  regurgitation. 

Fig.  8. 


Sphygmogram  of  the  trigeminal  pulse. 

The  Bigeminal  and  Trigeminal  Pulses. — Two  or  three 
regular  beats  followed  by  a  longer  pause.  They  have  the 
same  significance  as  the  irregular  pulse. 


THE   PULSE.  127 

The  Pulsus  Paradoxus. — One  which  is  more  or  less  sup-  \^ 
pressed  at  the  close  of  each  full  inspiration.     It  is  thought  to 
be  due  to  the  compression  of  the  great  vessels  by  inflammatory 
adhesions,  the  latter  being  stretched  during  the  act  of  inspira- 
tion.    It  is  frequently  noted  in  adherent  pericardium. 

The  Dicrotic  Pulse. — A  pulse  in  which  the  main  beat  is 
quickly  followed  by  a  secondary  wave  or  slight  rebound  of 
the  vessel.     The  secondary  or  dicrotic  wave  results  from  a 

Fig.  9. 


Sphygmogram  of  a  dicrotic  pulse. 

recoil  of  the  relaxed  vessels  after  the  latter  have  been  dis- 
tended  by  a  sharp  ventricular  contraction.  It  is  indicative  of 
low  arterial  tension,  and  is  noted  especially  in  febrile  diseases 
and  low  states  of  the  nervous  system. 


Other  Variations  in  the  Pulse. 

The  High-tension  Pulse. — One  in  which  the  force  of  the 
beat  is  relatively  increased.  The  tension  may  be  roughly 
estimated  by  noting  the  amount  of  pressure  of  the  fingers  that 
is  required  to  arrest  the  beat. 

A  high-tension  pulse  is  observed  in  many  conditions,  notably 
in  cardiac  hypertrophy,  excitement  of  the  heart,  chronic  ne- 
phritis ;  in  cerebral  affections  irritating  the  vaso-motor  centre, 
such  as  apoplexy,  tumors,  and  beginning  meningitis ;  after 
the  use  of  certain  drugs,  as  digitalis,  ergot,  and  alcoholic 
stimulants ;  in  chills ;  in  pregnancy ;  in  certain  neuroses,  as 
angina  pectoris,  epileptic  and  hysterical  seizures  ;  and  from 
contraction  of  the  capillaries  by  irritants  generated  in  the  body, 
as  in  lithsemia,  gout,  uraemia. 


128  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

The  Low-tension  Pulse. — This  is  also  observed  in  many 
conditions,  notably  in  degeneration  of  the  heart,  in  collapse, 
in  debility,  in  fevers,  and  in  low  states  of  the  nervons  system. 

Venous  Pulse. — A  true  jugidar  pulsation  is  often  noted  in 
tricuspid  regurgitation.  A  venous  pulse  in  the  dorsum  of  the 
hand  may  be  due  to  (1)  forcible  propulsion  of  blood  through 
the  capillaries,  as  in  aortic  regurgitation  with  great  hypei- 
trophy  of  the  left  ventricle ;  or  (2)  to  extreme  relaxation  of 
the  arterioles  and  capillaries,  permitting  the  transmission  of 
the  pulse-wave,  as  in  grave  cachexia  and  anaemia. 

Asymmetrical  Radial  Pulses. — May  result  from :  (1) 
Anomalies  in  the  distribution,  size,  and  division  of  one  of 
the  vessels.  (2)  '  Aortic  aneurism.  (3)  An  embolism  or  an 
atheromatous  plate  within  the  vessel.  (4)  Fractures,  luxations, 
or  inflammatory  exudations  causing  compression  of  the  vessel. 
(5)  Compression  of  one  vessel  by  tumors  within  or  without 
the  thorax. 

"Water-hammer  Pulse  "  {Corrigcm's  Pulse). — Characterized 
by  a  short,  powerful  beat,  which  suddenly  collapses.  The 
peculiar  pulsation  may  be  distinctly  visible,  not  only  in  the 
carotids  but  throughout  the  brachial  artery.  This  pulse  is 
diagnostic  of  aortic  regurgitation  during  the  period  of  compen- 
sation, and  its  force  is  due  to  the  excessive  ventricular  hyper- 
trophy and  to  the  large  amount  of  blood  expelled  with  each 
systole ;  its  sudden  recession  is  due  to  the  incompetent  valves 
failing  to  support  the  column  of  blood. 

PAIiPITATIOlNr. 

Definition. — A  rapid  and  tumultuous  action  of  the  heart 
perceptible  to  the  patient.  Rapidity  not  perceptible  to  the 
patient  is  not  termed  palpitation. 

Etiology. — It  may  result  from  :  (1)  Reflex  irritation,  as 
from  gas  or  acid  in  the  stomach.  (2)  Excitement,  mental 
or  physical.  (3)  Organic  heart  disease.  (4)  Exophthalmic 
goitre.  (5)  Over-work,  as  in  the  "irritable  heart"  of  un- 
trained recruits.  (6)  Anaraia.  (7)  Hysteria.  (8)  An  inde- 
pendent neurosis  (Essential  Paroxysmal  Tachycardia). 


DROPSY GENERAL,   CYANOSIS.  129 


DROPSY. 

Definition. — An  unnatural  collection  of  serous  fluid  in 
the  tissues  or  cavities  of  the  body.  * 

Etiology. — Dropsy  results  from  :  (1)  Venous  stasis,  from 
chronic  heart,  liver,  and  lung  diseases,  and  from  local  obstruc- 
tion to  the  venous  circulation  by  tumors,  pregnant  uteri,  or 
varicose  conditions.  The  last  is  a  common  cause  of  oedema 
in  the  legs  of  old  people.  (2)  Alterations  in  the  blood  or 
capillaries,  as  in  Bright's  disease,  anaemia,  and  inflammation. 
Cardiae  dropsy  usaaily  begins  in  the  feet  and  ascends.  ~^ 

OENEKAL  CYANOSIS. 

Definition. — Blueness  of  the  surface  from  insufiicient  oxi- 
dation of  the  blood. 

Etiology. — Cyanosis  results  from  :  (1)  Conditions  which 
obstruct  the  entrance  of  air,  as  croup  ;  oedema  of  the  larynx  ; 
tumors  or  foreign  bodies  in  the  air-passages;  tumors  pressing  on 
the  air-passages ;  emphysema  ;  pneumonia ;  pleurisy ;  paralysis 
of  the  respiratory  muscles,  as  in  bidbar  palsy ;  and  spasm  of 
the  respiratory  muscles,  as  in  epilepsy,  tetanus,  etc.  (2)  An 
inability  to  get  blood  to  the  air,  as  in  all  forms  of  chronic 
heart  disease  ending  in  pulmonary  congestion. 

Congenital  Cyanosis  is  usually  associated  with  stenosis  of 
the  pulmonary  orifice,  an  imperfect  ventricular  septum,  or  a 
patulous  foramen  ovale;  it  probably  results  not  so  much 
from  direct  mixture  of  venous  and  arterial  blood,  as  from  the 
failure  of  the  blood  to  reach  the  lung,  or  from  general  venous 
congestion. 


130  DISEASES  OF  THE   CIECULATOEY   SYSTEM. 


PERICARDITIS. 

Definition.  —  An  inflammation  of  the  pericardium,  or 
serous  covering  of  the  heart. 

Etiology. — (1)  Idiopathic,  from  exposure.  (2)  Traumatic. 
(3)  Secondary  to  neighboring  inflammations,  as  jsleurisy, 
phthisis,  pneumonia,  mediastinal  disease.  (4)  Secondary  to 
some  general  disease,  as  rheumatism,  Bright's  disease,  septi- 
caemia, tuberculosis,  and  the  eruptive  fevers. 

Pathology. — In  the  early  stage  the  membrane  is  red, 
sticky  and  lustreless;  and  if  the  process  now  ceases,  the  con- 
dition is  termed  dry  pericarditis. 

If,  however,  the  inflammation  continues,  an  exudate  is 
formed  which  may  be:  (1)  Sero-fibrinous,  (2)  fibrinous,  or 
(3)  purulent.  In  the  sero-fibrinous  form  there  is  little 
lymph,  the  exudate  being  mainly  composed  of  straM'--colored 
serum  (a  few  ounces  to  several  pints),  which  in  favorable  cases 
is  gradually  absorbed. 

In  the  fibrinous  form,  serum  is  scant  and  the  membrane  is 
covered  with  a  butter-like  exudate,  which  subsequently  or- 
ganizes and  unites  more  or  less  closely  the  pericardial  surfaces, 
causing  adherent  pericardium.  The  adhesions  oflfer  resistance 
to  the  ventricular  contractions  and  ultimately  induce  cardiac 
hypertrophy.  In  rare  instances  the  fibrinous  exudate  becomes 
calcified. 

In  the  purulent  form,  death  usually  results ;  but  evacua- 
tion of  the  pus  may  be  followed  by  union  of  the  pericardial 
surfaces,  and  ultimate  recovery. 

Symptoms. — Moderate  fever,  prsecordial  pain  and  tender- 
ness, dry  cough,  dyspnoea,  and  palpitation.  The  pulse  is  at 
first  rapid  and  forcible,  but  later  weak  and  irregular. 

Physical  Signs.     First  Stage. — Dry  pericarditis. 

Inspection. — Negative. 

Palpation. — Sometimes  a  fremitus,  from  the  grating  of  the 
roughened  pericardial  surfaces. 

Percussion. — Negative. 


PERICARDITIS.  131 

Auscultation — A  superficial  to-and-fro  friction-sound,  usu- 
ally heard  best  at  the  base  of  the  heart  and  not  transmitted, 
to  any  extent,  beyond  the  prsecordia. 

Second  Stage. — Sero-fibrinous  eifusion. 

Inspection. — Bulging  of  the  prsecordia. 

Palpation. — The  apex-beat  is  feeble  or  lost.  If  detected, 
it  is  pushed  upwards  and  to  the  left. 

Percussion. — Increased  area  of  dulness,  triangular  in  shape 
with  the  base  down. 

Auscultation. — The  heart-sounds  are  muffled,  feeble,  and 
distant. 

Purulent  effusion  yields  similar  signs,  but  in  addition, — 
(1)  the  symptoms  of  hectic  fever,  viz :  high  and  irregular 
fever,  sweats,  chills,  and  progressive  pallor.  (2)  Sometimes 
oedema  over  the  prsecordia ;  and,  (3)  in  doubtful  cases,  the 
aspirating  needle  reveals  pus. 

Fibrinous  pericarditis  (Adherent  pericardium)  is  often  diffi- 
cult to  recognize,  and  while  the  following  signs  suggest  the 
condition,  they  are  not  absolutely  diagnostic  : — 

Prsecordial  bulging,  a  weak  apex-beat  with  loud  sounds,  a 
systolic  retraction  or  dimpling  not  only  at  the  apex,  but  over  a 
large  part  of  the  prsecordia,  a  peculiar  diastolic  collapse  of  the 
jugular  veins  (Friedreich),  a  feeble  apex-beat,  with  a  forcible 
impulse  over  the  body  of  the  heart  (Paul). 

With  these  signs  there  are  often  symptoms  of  heart- failure, 
such  as  dyspnoea,  dropsy,  and  cyanosis. 

Diagnosis.  Acute  Endocarditis. — The  murmur  is  soft  and 
blowing,  not  harsh  ;  it  is  usually  single,  not  to-and-fro  ;  it  is 
somewhat  distant,  not  superficial ;  it  is  not  necessarily  heard 
best  at  the  base,  but  at  one  of  the  valve  points ;  it  is  not  con- 
fined to  the  prsecordia,  but  is  usually  transmitted;  and  it  is  not 
followed  by  the  signs  of  effusion. 

Pericardial  effusion  must  be  distinguished  from  cardiac  hy- 
pertrophy. In  hypertro])hy  the  area  of  dulness  is  increased, 
but  normal  in  outline ;  the  apex-beat  is  displaced  downwards 
and  to  the  left,  and  is  forcible ;  and  the  sounds  are  loud  and 
clear. 

Pericardial  effusion  and  cardiac  dilatation. — In  dilatation 
there  is  no  friction-sound  ;  the  apex  is  usually  displaced  down- 


132  DISEASES   OF   THiJ   CIKCULATOEY   SYSTEM. 

wards,  never  upwards;  the  area  of  didness  is  not  pyramidal, 
but  ex^tends  laterally;  the  sounds  are  not  muffled,  but  clear 
and  sharp. 

Prognosis. — In  the  dry  and  sero-fibrinous  forms  the  prog- 
nosis is  good  under  favorable  conditions.  In  the  purulent 
form  the  outlook  is  extremely  grave.  The  fibrinous  form, 
though  not  immediately  fatal,  is  very  serious  on  account  of  the 
secondary  changes  which  it  induces  in  the  cardiac  muscle. 

Treatment. — Absolute  rest.  Light  diet.  Opium  is  usu- 
ally required  to  insure  quiet  and  to  relieve  pain.  When  the 
action  of  the  heart  is  rapid  and  irregular,  either  aconite  or 
digitalis  may  be  administered  according  to  the  strength  of  the 
pulse. 

Local  Treatment. — In  severe  cases  apply  a  few  wet  cups, 
leeches,  or  a  blister  to  the  prsecordia.  In  other  cases,  an  ice- 
bag  or  poultice  may  give  relief. 

Pericardial  effusion  (Chronic  pericarditis). — When  the  effu- 
sion is  decided,  apply  small  blisters  over  the  prsecordia,  admin- 
ister iodide  of  potassium  (gr.  x  thrice  daily),  and  encourage 
diuresis  with  digitalis  or  caifeine,  and  catharsis  with  saline 
draughts. 

(1)  When  the  effusion  is  very  large,  (2)  when  it  creates 
much  disturbance,  as  dysj^noea,  cyanosis,  and  the  like,  (3) 
when  its  absorption  c;annot  be  accomplished  by  internal  reme- 
dies, or  (4)  when  it  is  purulent,  paracentesis  of  the  peri- 
cardium is  indicated.  The  needle  should  be  introduced  in  the 
fifth  interspace,  a  little  to  the  right  of  the  point  of  the  normal 
apex-beat.  When  the  effusion  is  purulent,  a  free  incision  offers 
a  slight,  and  the  only  chance  of  cure. 

In  adherent  jjericardium,  repeated  small  blisters  may  be 
employed  and  heart-failure  should  be  combated  with  digitalis 
and  similar  cardiac  tonics. 

OTHER  AFFECTIONS  OF  THE  PERICARDIUM. 

Hydropericardium  (Dropsy  of  the  pericardium)  results  from 
•pericarditis,  or  from  one  of  the  causes  of  general  dropsy,  as 
chronic  heart,  kidney,  or  lung  disease. 

Physical  Signs. — The  same  as  sero-fibrinous  pericarditis. 


ENDOCARDITIS.  133 

Haemopericardium  (Blood  in  the  pericardial  sac)  results 
from  the  rupture  of  an  aneurism,  rupture  of  the  heart,  trau- 
matism, and  cancerous  and  tuberculous  pericarditis. 

Physical  Signs. — The  same  as  hydropericardium.  It  is 
S]>eedily  fatal. 

Pneumopericardium  (Air  in  the  pericardium). — This  rare 
condition  results  from  external  wounds,  or  the  rupture  of  an 
air-containing  organ  into  the  pericardium,  as  the  perforation 
of  a  pyo-pneumothorax  into  the  pericardial  sac.  The  entrance 
of  a  septic  irritant  produces  pus  and  the  condition  becomes  a 
pneumo-pyopericardium. 

Physical  Signs. — Percussion  over  the  prsecordia  yields 
tympany  ;  and  auscultation,  splashing  and  metallic  sounds. 

ENDOCARDITIS. 

(Valvulitis.) 

Definition. — Inflammation  of  the  lining  membrane  of  the 
heart.     The  process  is  usually  confined  to  the  valves. 

Varieties. — (1)  Exudative,  or  vegetative  endocarditis 
(Endocarditis  veri'ucosa).  This  begins  as  an  acute  affection, 
but  usually  leads  to  chronic  interstitial  valvulitis.  (2)  Sclerotic, 
or  interstitial  valvulitis  (Chronic  endocarditis).  (3)  Ulcerative, 
or  malignant  endocarditis. 

Etiology. — Rheumatism  is  the  chief  cause.  At  least  50 
to  60  per  cent,  of  all  cases  of  acute  rheumatism  will  be  com- 
plicated with  endocarditis.  It  is  more  liable  to  complicate 
rheumatism  in  the  young  than  in  the  old.  There  is  no  rela- 
tion between  the  severity  of  the  rheumatic  disease  and  the 
liability  to  heart  complication.  The  specific  fevers,  chorea, 
septicaemia,  Bright's  disease,  syphilis,  tuberculosis,  alcoholism, 
and  excessive  muscular  exertion,  are  also  predisposing  causes. 
It  may  be  congenital.  It  rarely,  if  ever,  results  from  expo- 
sure to  cold  and  wet. 

Pathology. — Post-natal  endocarditis  most  commonly  in-"^ 
volves  the  valves  of  the  left  side  of  the  heart. 

Pre-natal  endocarditis  most  commonly  involves  the  valves 
of  the  right  side  of  the  heart. 

In  the  exudative  form  the  valve  is  red,  swollen,  lustreless, 


134  DISEASES    OF   THE   CIRCULATORY   SYSTEM. 

and  studded  with  numerous  bead-like  vegetations  which  are 
especially  marked  along  its  free  margins. 

These  vegetations  are  composed  of  proliferated  connective- 
tissue  cells,  the  superficial  layers  of  Avhich  have  undergone 
coagulation-necrosis,  and  are  covered  with  more  or  less  fibrin 
derived  from  the  blood. 

They  may  be  whipped  ofiF  by  the  blood-current,  and  be 
carried  as  emboli  to  distant  organs,  as  the  brain,  kidney,  and 
spleen  ;  but  more  commonly,  if  life  is  preserved,  they  are 
partially  absorbed,  and  the  remaining  proliferated  connective- 
tissue  cells  form  fibrous  tissue,  and  thus  sclerotic  valvulitis  is 
secondarily  induced. 

Sclerotic  valvulitis  may  arise  as*a  primary  disease,  and  is 
characterized  by  thickening,  curling  and  puckering  of  the 
valve  from  an  overgrowth  of  fibrous  tissue,  Avhich  is  often  as- 
sociated with  more  or  less  fatty  degeneration  of  the  cells  and 
a  deposition  of  lime  salts  in  their  midst. 

Symptoms  of  Acute  Endocarditis. — Subjective  phe- 
nomena are  often  absent,  and  auscultation  may  furnish  the 
only  indication  of  endocarditis,  namely,  a  prolongation  of  the 
heart-sound,  which  later  develops  into  a  distinct  murmur. 

In  many  cases  fever,  an  irregular  and  rapid  pulse,  palpita- 
tion, preecordial  distress,  and  dyspnoea  will  be  associated  symp- 
toms. 

Diagnosis. — Chiefly  by  physical  signs.  In  ijeriearditis  the 
friction-sound  is  to  and  fro,  superficial,  perhaps  modified  by 
pressure  of  the  stethoscope,  not  transmitted  much  beyond  the 
prsecordia,  and  is  followed  by  signs  of  effusion. 

Prognosis. — In  simple  endocarditis  the  prognosis  should 
be  guarded.  The  lesion  rarely  disappears,  and  permanent 
damage  to  the  valve  results.  Under  favorable  conditions, 
however,  compensatory  hypertrophy  of  the  heart  results,  and 
good  health  may  be  preserved  for  an  indefinite  period. 

Treatment. — Absolute  rest.  Treat  the  causal  condition. 
When  the  symptoms  are  marked,  apply  blisters,  mustard 
poultices,  leeches,  or  ice-bags  to  the  prsecordia. 

Support  the  system  with  moderate  doses  of  quinine.  When 
the  pulse  is  weak  and  irregular,  the  tincture  of  digitalis  (5  to 
10  di'ops)  will  be  of  great  value.     If  the  pulse  is  rapid  and 


CHRONIC  VALVULAR   AFFECTIONS.  135 

strong,  aconite  may  be  employed  instead  of  digitalis.  Absor- 
bents like  the  iodides  are  of  no  value.  Convalescence  should 
be  prolonged  and  guarded,  so  that  compensatory  hypertrophy 
may  result. 

CHRONIC  VAJLVULAR  AFFECTIONS. 

Period  of  Compensation. — By  compensation  is  meant  an  in- 
crease in  the  size  and  strength  of  certain  cardiac  chambers 
sufficient  to  enable  the  arterial  system  to  receive  its  normal 
amount  of  blood,  notwithstanding  obstruction  or  regurgitation 
at  one  or  more  of  the  valves. 

The  duration  of  this  period  is  indefinite,  and  depends  largely 
on  the  amount  of  damage  sustained  by  the  heart  and  the  hy- 
gienic conditions  to  which  the  patient  is  subjected. 

During  perfect  compensation,  the  disease  is  indicated  by 
physical  signs,  symptoms  being  entirely  absent. 

Aortic  Stenosis,  or  Aortic  Obstruction. 

Definition. — Obstruction  to  the  flow  of  blood  into  the 
aorta  from  thickening  or  adhesion  of  the  aortic  segments. 

Physical  Signs.  Inspection. — If  the  heart  is  strong,  the 
apex-beat  is  forcible,  and  is  noted  downward  and  to  the  left. 

Palpation  confirms  inspection,  and  sometimes  detects  a  sys- 
tolic thrill  at  the  base  of  the  heart. 

Percussion  may  yield  an  increased  area  of  cardiac  dulness, 
especially  to  the  left. 

AiLSCultation. — A  systolic  murmur  with  maximum  intensity 
in  the  right  second  intercostal  space,  and  transmitted  into  both 
carotid  arteries. 

Pulse. — During  perfect  compensation,  the  pulse  is  quite 
normal,  but  when  the  heart  weakens,  it  becomes  small  and 
slow. 

Compensation. — From  obstruction  to  the  outflow  of  blood, 
the  left  ventricle  becomes  hypertrophied. 

Sequence. — Mitral  regurgitation.  Weakening  and  dilata- 
tion of  the  left  ventricle  prevents  perfect  closure  of  the  mitral 
orifice,  and  relative  insufficiency  results. 


> 


136  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

Aortic  Insufficiency,  or  Aortic  Regurgitation. 

Definition. — Failure  of  the  aortic  valves  to  prevent  a  re- 
turn of  blood  to  the  ventricle,  from  rupture  or  inflammatory 
contraction  of  the  segments,  or  from  dilatation  of  the  orifice. 

Physical  Signs.  Inspection. — Apex-beat  forcible,  and 
noted  far  downward  and  to  the  left.     The  prsecordia  may  bulge. 

Palpation. — Confirms  inspection. 

Percussion. — Increased  area  of  cardiac  dulness,  especially  to 
the  left.  . 

Auscultation. — A  diastolic  murmur  with  maximum  intensity 
in  the  right  second  intercostal  space,  and  transmitted  down  the 
sternum  and  towards  the  apex. 

Pulse. — The  arteries,  especially  the  carotids,  brachials,  and 
radials,  pulsate  visibly.  Palpation  detects  the  "  water-hammer," 
or  Corrigan's  pulse,  i.  e.,  a  short,  full,  and  receding  pulse. 

The  extreme  cardiac  enlargement  makes  the  pulse  full,  and 
the  prompt  leakage  back  into  the  ventricle  makes  it  short  and 
receding.  Elevation  of  the  arm,  during  palpation  of  the  radial, 
makes  this  pulse  more  apparent,  as  the  position  favors  regur- 
gitation. A  capillary  pulse  is  sometimes  present.  It  may  be 
UQted  at  the  root  of  the  finger-nail  by  an  alternate  blushing 
and  paling,  synchronous  with  the  heart-beats. 

Compensation. — Dilatation  and  hypertrophy  of  the  left 
ventricle.  Dilatation  results  from  the  reception  of  such  a  large 
quantity  of  blood  during  diastole,  and  hypertrophy  follows 
from  the  increased  effort  which  the  ventricle  must  put  forth 
in  emptying  itself  of  this  extra  quantity  of  blood. 

This  extremely  dilated  and  hypertrophied  heart  has  been 
called  the  cor  hovinum,  or  ox-heart. 

Sequence.  —  Mitral  regurgitation.  The  dilatation  and 
weakening  of  the  ventricle  prevent  perfect  closure  of  the 
mitral  orifice,  and  relative  insufficiency  results. 

Mitral  Stenosis,  or  Miti*al  Obstruction. 

Definition. — Obstruction  to  the  flow  of  blood  through  the 
mitral  orifice,  from  thickening  or  adhesion  of  the  mitral 
seg-ments. 


CHRONIC  VALVULAR   AFFECriONS.  137 

Physical  Signs.  Inspection. — Apex-beat  is  not  much 
displaced.  Theue  is  sometimes  bulging  over  the  lower  part  of 
the  sternum.       | 

Palpation. — -J^  rough  presystolic  thrill  near  the  apex. 

Pe/'CMSSion. -^Increased  area  of  dulness,  especially  to  the 
right. 

Auscultation. — A  prolonged,  rough,  churning  murmur, 
presystolic  in  time,  heard  most  distinctly  a  little  above  and 
to  the  left  of  the  apex,  and  not  transmitted. 

The  second  sound  at  the  pulmonary  cartilage  "is  accentuated 
from  the  enlaro-ement  of  the  right  ventrfcle. 

Pulse. — During  the  period  of  compensation  the  pulse  is 
small  and  regular. 

Compensation. — From  obstruction  to  the  outflow  of  blood 
the  left  auricle  becomes  enlarged ;  when  it  loses  power,  the 
blood  accumulates  in  the  lung,  and  to  overcome  this  pulmonary 
resistance  the  right  ventricle  l:)ecomes  hypertrophied. 

There  is  no  strain  on  the  left  ventricle,  aud  hence  that  cham- 
ber is  not  enlarged. 

Sequence. — Tricuspid  regurgitation.  Dilatation,  of  the 
right  ventricle  prevents  perfect  closure  of  the  tricuspid  orifice, 
and  relative  insufficiency  results. 

Mitral  Insufficiency,  or  Mitral  Regurgitation. 

Definition — Imperfect  closure  of  tlie  mitral  orifice  from 
rupture  or  inflammatory  contraction  of  the  mitral  segments  ;  or 
from  dilatation  or  weakening  of  the  left  ventricle,  ])reveuting 
perfect  coaptation  of  normal  valves. 

Physical  Signs.  Inspection.  —  Apex-beat  forcible,  and 
noted  downward  and  to  the  left.     The  prsecordia  may  bulge. 

Palpation  confirms  inspection. 

Percitssion.— Increased  area  of  dulness  to  the  right  and 
left. 

Auscultation. — A  systolic  murmur,  with  maximum  inten- 
sity at  the  apex,  and  transmitted  to  the  left  axilla  and  to  the 
angle  of  the  scapula. 

Pulse. — During  period  of  compensation  normal,  but  very 
irregular  when  the  heart  weakens. 


138  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Compensation. — The  left  auricle  enlarges  from  the  extra 
amount  of  blood  that  it  receives ;  when  it  weakens,  the  lungs 
become  congested  and  right  ventricular  hypertrophy  follows. 

The  left  ventricle  also  becomes  hypertrophied  from  its  effort 
to  move  the  large  quantity  of  blood  which  it  receives  from  the 
distended  auricle  during  each  diastole. 

Sequence. — Tricuspid  regurgitation.  Weakening  and  dila- 
tation of  the  right  ventricle  prevent  perfect  closure  of  the  tri- 
cuspid orifice. 

Tricuspid  Stenosis,  or  Tricuspid  Obstruction. 

This  lesion  is  comparatively  rare.  It  gives  rise  to  enlarge- 
ment of  the  heart  and  a  presystolic  murmur,  which  is  heard 
most  distinctly  at  the  xiphoid  cartilage. 

Tricuspid  Insufficiency,  or  Tricuspid 
Regurgitation. 

Definition. — Imperfect  closure  of  the  tricuspid  orifice 
from  inflammatory  shortening  of  the  valves;  or,  more  com- 
monly, from  dilatation  of  the  right  ventricle  secondary  to 
mitral  disease  or  to  chronic  lung  disease. 

Physical  Signs.^ — Enlargement  of  the  heart ;  a  systolic 
murmur,  heard  most  distinctly  just  above  the  xiphoid  cartilage, 
and  associated  with  pulsation  of  the  jugular  vein,  and  in  bad 
cases,  with  pulsation  of  the  liver. 

Pulmonary  Stenosis,  or  Pulmonary  Obstruction. 

This  very  rare  lesion  is  always  congenital,  and  may  be  sus- 
pected when  a  systolic  murmur  is  heard  most  distinctly  at  the 
left  second  intercostal  space,  and  is  not  transmitted  into  the 
vessels  of  the  neck. 

Pulmonary  Insufficiency,  or  Pulmonary 
Regurgitation. 

This  is  very  rare,  and  is  always  congenital.  It  produces  a 
diastolic  murmur,  which  is  heard  most  distinctly  in  the  left 
second  intercostal  space. 


CHRONIC   VALVULAR   AFFECTIONS.  139 

Period  of  Lost  Compensation. — Lost  compensation  usually 
results  from :  (1)  Increasing  damage  to  the  valves  ;  (2)  senility, 
leading  to  arterial  and  cardiac  degeneration ;  (3)  some  inter- 
current disease,  throwing  additional  strain  on  the  heart;  and 
(4)  undue  physical  exertion. 

During  this  period  subjective  symptoms  appear.  When  the 
heart  weakens,  no  matter  what  the  original  valvular  lesion 
was,  it  becomes  unable  to  fill  the  arteries,  and  the  blood  is 
dammed  back  in  the  lungs,  and  venous  congestion  of  the 
organs  follows. 

Sv^rPTOMS.  —  Pulmonary  congestion  produces  dyspnoea, 
asthma,  haemoptysis,  and  often  chronic  bronchial  catarrh  with 
cough  and  expectoration. 

Hepatic,  stomachic,  and  intestinal  congestion  produce  dys- 
pepsia. Renal  congestion  produces  scanty  albuminous  urine, 
and  later  nephritis. 

General  venous  congestion  produces  cyanosis,  and  dropsy 
which  begins  in  the  feet  and  mounts  upwards. 

Cerebral  ansemia  or  congestion  produces  headache,  vertigo, 
and  syncopal  attacks. 

In  aortic  disease,  especially  aortic  stenosis,  cerebral  symp- 
toms are  often  marked.  In  mitral  disease,  pulmonary  symp- 
toms are  usually  marked. 

Prognosis  of  Chronic  Valvular  Affections. — The 
extent  of  damage  can  never  be  accurately  determined  by  the 
quality  or  intensity  of  the  murmur. 

All  things  being  equal,  the  following  is  probably  the  order 
of  gravity  in. the  various  valvular  lesions:  (1)  Tricuspid  re- 
gurgitation, (2)  aortic  regurgitation  (often  ending  in  sudden 
death),  (3)  aortic  stenosis,  (4)  mitral  stenosis,  and  (5)  mitral  re- 
gurgitation. 

The  following  are  unfavorable  conditions  :  Early  life,  ad- 
vanced years,  great  cardiac  enlargement,  irregular  heart-action, 
liability  to  recurring  attacks  of  rheumatism,  bad  hygienic 
surroundings^  and  symptoms  of  congestion  of  the  lungs,  kid- 
ney or  digestive  tract. 

In  proportion  to  the  absence  of  these  conditions,  the  prog- 
nosis Ijecomes  favorable.  In  many  cases  life  is  not  materially 
shortened. 


140  DISEASES    OF   THE   CIRCULATORY   SYSTEM. 

Treatment. — When  compensation  is  perfect,  the  treat- 
ment is  purely  hygienic. 

When  there  is  sudden  heart-faikire  in  valvular  disease,  in- 
dicated by  orthopnoea  and  cyanosis,  rest  should  be  absolute, 
hot  applications  should  be  applied  to  the  prtecordia,  and  diffu- 
sible stimulants  administered  hypodermically  :  spirits  of  am- 
monia (20-30  minims),  whiskey  (30—60  minims),  sulphate 
of  strychnine  (gr.  ^,  repeated  once  or  twice),  and  especially 
nitro-glyceriue  (1-2  drops  of  1  per  cent,  alcoholic  solution) 
may  be  so  employed  ;  the  last,  in  addition  to  being  a  highly 
diffusible  stimulant,  has  the  power  of  dilating  the  peripheral 
bloodvessels.  Venesection  (10-20  ounces)  is  often  of  consid- 
erable value  in  these  cases. 

When  compensation  is  gradually  lost,  rest,  a  light,  nutritious 
diet,  and  tinct.  digitalis  (10-20  drops  three  or  four  times  daily) 
are  the  most  important  therapeutic  measui'es.  Tinct.  stro]ihan- 
thlis  sometimes  succeeds  when  digitalis  fails.  Mild  laxatives, 
such  as  massa  hydrargyri  (gr.  3-5),  greatly  influence  the 
absorption  of  digitalis.  When  there  is  moderate  dropsy  the 
following  pill  is  very  efficient : — 

^   Mass.  hydrargyri, 

Pulv.  digitalis, 

Pulv.  sciilse,  aa  gr.  xxiv. — M. 
Ft.  in  pil.  'No.  xxiv. 
Sig. — One  pill  thrice  daily. 

Strychnine  is  often  a  valuable  adjunct  to  digitalis,  especially 
when  there  are  indications  of  fatty  degeneration  of  the  heart. 
When  there  is  anaemia,  iron  is  indicated,  and  it  may  be  given 
with  digitalis  and  strychnine,  as  in  the  following  pill : — 

]^    Str3rchnin.  sulph.,  gr.  j  ; 
Pulv.  digitalis, 

Ferri   carb.  sacchar.,  aa  gr.  xxx. — M. 
Ft.  in  pil.  No.  xxx. 
Sig. — One  pill  thrice  daily. 

When  there  is  much  bronchitis  and  dyspnoea,  digitalis  with 
ammonia  and  senega  is  an  efficient  combination.  (Barlow.) 
When  dyspnoea  is  marked  and  the  pulse  is  strong,  nitro- 
glycerine (1-2  drops  thrice  daily,  or  gr.  ^-00  thrice  daily),  if 
well  borne,  may  be  of  much   service.      In  extreme  dropsy 


ACUTE   ULCERATIVE   ENDOCARDITIS.  141 

free  catharsis  should  be  induced  by  compound  jalap  powder 
(gr.  xx-xxx),  or  a  concentrated  solution  of  Epsom  salts  (oSs), 
and  diuresis  established  by  the  infusion  of  digitalis  (f  5  ss-f,lj, 
thrice  daily).  In  persistent  anasarca,  aspiration  of  serous  sacs 
and  puncture  of  the  legs  may  be  required. 

When  there  is  excessive  hypertrophy,  indicated  by  prtecor- 
dial  distress  and  a  full,  regular  pulse,  without  dropsy,  aconite 
in  small  doses  will  prove  efficient. 

ACUTE  ULCERATIVE  ENDOCARDITIS. 

(Mycotic  Endocarditis,  Malignant  Endocarditis.) 

Definition. — A  rapidly-destructive  form  of  endocarditis, 
characterized  by  necrosis  or  ulceration  of  the  valves  and  the 
deposition  of  colonies  of  micrococci. 

Etiology. — It  may  begin  as  a  primary  disease,  or  be 
engrafted  on  a  simple  endocarditis.  It  may  result  in  the  de- 
bilitated from  overwork  or  exposure  ;  it  sometimes  complicates 
the  puerperium ;  it  generally  follows  septicemia  or  one  of  tlie 
specific  fevers — such  as  pneumonia,  erysipelas,  and  scarlet 
fever. 

Pathology. — The  valves  are  the  seat  of  ulcers,  deep  ab- 
scesses, and  soft,  yellowish  vegetations,  which  have  undergone 
partial  necrosis.  Microscopic  examination  reveals  myriads  of 
micrococci. 

Symptoms.  1.  General. — High  and  irregular  fever,  re- 
peated chills,  profuse  sweats,  great  prostration,  often  delirium 
and  stupor,  hurried  breathing,  rapid  irregular  pulse,  brown 
fissured  tongue.    Jaundice  and  diarrhoea  are  frequently  present. 

2.  Cardiac  Symptoms. — Precordial  pain,  palpitation,  and 
often  a  blowing  murmur  at  one  or  more  of  the  valves.  Mur- 
murs may  be  absent. 

3.  Embolic  Symptoms. — Peripheral  emboli  yield  a  petechial 
rash;  renal  embolism  may  yield  bloody  urine;  splenic  em- 
bolism may  yield  a  painful  spleen  ;  cerebral  embolism  may 
yield  paralysis. 

Diagnosis. — Is  often  difficult. 

Meningitis. — Cardiac  symptoms,  high  fever,  profuse  sweats, 
and  chills  will  usually  separate  it  from  meningitis. 


142  DISEASES   OF  THE   CIECULATOEY  SYSTEM. 

Typhoid  Fever. — Abrupt  ODset,  cardiac  symptoms,  embolic 
symptoms,  sweats,  chills,  and  the  absence  of  an  abdominal 
rose-colored  rash  Avill  separate  it  from  typhoid  fever. 

Malarial  Fever. — In  endocarditis  the  2)^<^f'8fnodiu'm  malarice 
is  not  found  in  the  blood. 

PROGNOSIS. — Almost  invariably  fatal.  Duration  is  from  a 
few  days  to  several  wrecks. 

Treatment. — Ice-bags  to  the  heart.  Light  nutritious  diet. 
Stimulants. 

ACUTE  MYOCAKDITIS. 

Definition. — Acute  inflammation  of  the  heart  muscle. 

Etiology. — It  is  almost  always  secondary  to  endocarditis 
or  to  pericarditis.  As  a  primary  affection  of  the  heart,  it 
may  be  due  to  rheumatism,  or  to  one  of  the  infectious  fevers. 

Pathology. — The  muscle  substance  is  pale,  flabby,  and 
friable.  Microscopic  examination  reveals  fatty  degeneration 
of  the  muscle  fibres  and  an  infiltration  of  the  connective  tis- 
sue with  leucocytes. 

Symptoms. — The  symptoms  are  often  masked  by  the  pri- 
mary disease.  Dyspnoea,  prsecordial  pain  and  distress,  a  weak, 
very  rapid,  small,  and  irregular  pulse,  a  feeble  impulse,  and 
weak  sounds  suggest  the  condition. 

Treatment. — Absolute  rest,  and  the  use  of  cardiac  stimu- 
lants, like  strychnine,  caffeine,  digitalis,  and  alcohol. 

FIBROID  HEART. 

(Myo-degeneration  of  the  Heart,  Chronic  Myocarditis,  Indurated 
Degeneration.) 

Etiology. — This  condition  is  dependent  upon  atheroma  or 
sclerosis  of  the  coronary  arteries.  The  indirect  causes  are 
rheumatism,  gout,  syphilis,  alcoholism,  endocarditis  and  peri- 
carditis. 

Pathology. — The  heart  is  usually  hypertrophied  or 
dilated,  aud  is  the  seat  of  grayish-white  patches,  which  repre- 
sent overgrown   connective   tissue.      The  papillary  muscles, 


HYPEETEOPHY    OF  THE   HEAET.  143 

columnse  carnese,  and  the  wall  of  the  left  ventricle  near  the 
apex  are  the  parts  most  frequently  affected. 

Arterial  sclerosis  causes  necrosis,  and  this  in  turn  is  followed 
by  a  proliferation  of  the  connective  tissue. 

The  fibroid  areas  sometimes  yield  to  the  endocardial  pres- 
sure and  cause  aneurism  of  the  heart. 

Symptoms. — It  manifests  the  same  symptoms  as  fatty  de- 
generation, viz :  dyspnoea,  cough,  weak  and  irregular  pulse, 
palpitation,  anginoid  pains,  dropsy,  etc. 

Treatment. — Same  as  in  fatty  heart. 

HYPERTROPHY  OF  THE  HEART. 

Definition. — Enlargement  of  the  heart  due  to  an  over- 
growth of  its  muscle. 

Etiology. — It  always  results  from  increased  work,  and 
this  may  be  due  to  :  (1)  Too  much  blood  to  be  moved  from 
the  heart,  as  in  the  regurgitant  valvular  lesions.  (2)  Obstruc- 
tion to  the  outflow  of  blood  at  the  valves,  as  in  the  stenoses ;  or 
in  the  pulmonary  or  the  systemic  circulation,  as  in  emphysema 
and  Bright's  disease.  (3)  Resistance  to  ventricular  contrac- 
tion by  pericardial  adhesions.  (4)  Undue  physical  exertion 
long  continued.  (5)  Disturbed  innervation  from  drugs,  such 
as  tobacco ;  or  from  disease,  as  exophthalmic  goitre. 

Varieties. — (1)  Simple  hypertrophy.  Thickened  muscle 
and  cavities  of  normal  size.  (2)  Eccentric  hypertrophy  (hyper- 
trophy with  dilatation).  Thickened  muscle  and  cavities  di- 
lated. (3)  ConcentriG  hypertrophy.  Thickened  muscle  and 
cavities  diminished  in  size.     Always  congenital. 

Pathology. — The  average  weight  of  the  normal  heart  is 
eight  or  nine  ounces  ;  in  hypertrophy  it  may  weigh  two  or 
three  times  as  much.  One  or  both  chambers  may  be  eularged  ; 
the  left  is  the  one  most  commonly  affected.  The  muscle  is 
firm  and  of  a  deep  red  color.  Histologically  the  muscle-ele- 
ments are  increased  in  size  and  number. 

Symptoms. — Unless  the  hypertrophy  is  more  than  compen- 
satory no  symptoms  result.  Extreme  hypertrophy  is  indicated 
by  prsecordial  distress,  palpitation,  a  strong  pulse,  and  some- 
times by  the  phenomena  of  cerebral  hypersemia,  viz  :    flushed 


\ 


144  DISEASES   OF   THE   CIECULATORY   SYSTEM. 

face,  ringing  in  the  ears,  flashes  of  light,  headache,  and  dis- 
turbed sleep. 

Physical  Signs.  Inspection. — Prsecordial  bulging.  For- 
cible impulse.  The  apex-beat  is  displaced  downward  and  to 
the  left. 

Palpation. — A  heaving  impulse. 

Percussion. — Increased  area  of  cardiac  dulness. 

Auscultation. — Sounds  are  dull  and  loud. 

SEQUELiE. — Apoplexy,  fatty  degeneration  of  the  heart  and 
subsequent  dilatation,  valvular  disease,  and  arterial  degeneration. 

Diagnosis. — Hypertrophy  and  dilatation.  These  two  con- 
ditions are  commonly  associated,  but  the  preponderance  of  di- 
latation will  be  indicated  by  a  feeble  fluttering  im])ulse,  weak 
sounds,  a  weak,  irregular,  or  intermittent  pulse,  and  by  symp- 
toms of  heart-failure,  such  as  dyspnoea,  dropsy,  etc. 

Treatment. — When  the  hypertrophy  is  excessive,  recom- 
mend graduated  exercise  and  a  light  diet,  and  employ  such  seda- 
tives as  tincture  of  aconite  (gtt.  j-ij  thrice  daily)  or  tincture  of 
veratrum  viride  (gtt.  j-ij).  The  bromides  are  often^  valuable 
adjuncts. 

DILATATION  OF  THE  HEAKT. 

Definition. — Enlargement  of  the  heart  due  to  stretching 
of  its  walls. 

Varieties. — (1)  Dilatation  with  thickening  of  the  walls 
(eccentric  hypertrophy),  and  (2)  Dilatation  with  thinning  of 
the  walls. 

Etiology. — Dilatation  results  from  excessive  endocardial 
pressure,  as  in  sudden  extreme  exertion  and  in  valvular  disease, 
and  (2)  Impaired  nutrition  of  the  cardiac  muscle,  as  in  low 
fevers,  valvular  disease,  and  atheroma  of  the  coronary  arteries. 

Pathology. — One  or  both  chambers  may  be  dilated ;  the 
right  is  the  one  most  commonly  aifected.  The  condition  is  usu- 
ally associated  with  hypertrophy  aud  fatty  degeneration.  The 
muscle  may  be  normal  in  appearance,  but  very  frequently  it  is 
pale  and  soft. 

Symptoms. — So  long  as  the  associated  hypertrophy  keeps 
pace  with  the  dilatation,  no  symptoms  result ;  but  when  dila- 
tation   preponderates,    the   following   symptoms    of  venous 


FATTY  DEGENEEATION   OF   THE   HEART.  145 

stasis  appear  :  dyspnoea,  cough,  dyspepsia,  scanty  urine,  dropsy, 
and  a  feeble,  irregular  pulse. 

Disturbed  innervation  often  causes  praecordial  distress  and 
palpitation. 

Physical  Signs. — Apex-beat  is  diffuse  and  weak  ;  it  may 
be  visible  and  yet  not  palpable  (Walshe).  When  the  right 
heart  is  involved  an  impulse  is  noted  below  the  xiphoid  carti- 
lage. 

Palpation. — A  diffuse,  feeble,  and  fluttering  impulse. 

Percussion. — The  area  of  dulness  is  increased,  especially 
laterally. 

Auscultation. — The  sounds  are  weak  and  sharp.  The  first 
sound  loses  its  muscular  element  and  resembles  the  second. 
Co-existing  valvular  lesions  induce  murmurs. 

Diagnosis. — Pericardial  effusion.  In  this  condition  a  fric- 
tion-sound is  frequently  present ;  the  outline  of  dulness  is  py- 
riform  with  the  base  below,  and  is  not  nearly  so  broad  as  in 
dilatation ;  and  the  sounds  are  distant  and  muffled ;  and  the 
apex-beat  is  displaced  upwards. 

Treatment. — Rest,  Light  and  nutritious  diet.  Improve 
the  general  condition  by  careful  hygienic  regulations,  and  the 
use  of  such  tonics  as  iron,  quinine,  arsenic,  and  the  like.  Car- 
diac tonics,  as  digitalis,  caffeine,  strophanthus,  and  strychnine, 
are  indicated. 

In  sudden  dilatation,  use  diffusible  stimulants,  as  brandy, 
ammonia,  or  strychnine,  hypodermically. 

FATTY  DEGENERATION  OF  THE  HEART. 

Definition. — The  term  fatty  heart  is  applied  to  (1)  fatty 
infiltration,  in  which  an  abnormal  amount  of  fat  is  deposited  in 
and  upon  the  heart ;  and  (2)  to  fatty  degeneration,  in  which 
the  cardiac  muscle  has  been  metamorphosed  into  fat. 

Fatty  Infiltration. 

Etiology. — It  is  a  part  of  general  obesity,  and  hence  re- 
sults from  an  hereditary  tendency,  a  rich  diet,  and  sedentary 

habits. 

10 


146  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Pathology. — The  heart  may  be  completely  imbedded  in 
fat,  the  grooves  along  the  larger  bloodvessels  being  favorite 
seats  of  deposit.  Fat  is  also  found  between  the  muscle  fibres, 
although  the  latter  may  be  perfectly  normal. 

SYzyiPTOMS. — Shortness  of  breath  increased  by  exertion,  a 
weak  but  regular  pulse,  precordial  distress,  a  tendency  to  pul- 
monarv  congestion,  Avith  a  resulting  obstinate  bronchitis,  and 
sluggish  digestion. 

Prognosis. — Favorable. 

Treatment. — -A  regulated  diet,  in  which  the  use  of  fats, 
starches,  and  sugars  is  restricted.  Graduated  exercise.  The 
Turkish  bath  under  supervision.  Heart  tonics,  like  digitalis 
and  strychnine,  are  sometimes  indicated. 

Fatty  Degeueratiou  of  tlie  Heart. 

Etiology. — (1 )  It  follows  hypertrophy  in  valvular  disease. 

(2)  It  is  frequently  due  to  atheroma  of  the  coronary  artery. 

(3)  It  is  a  common  result  of  malnutrition  from  old  age,  wast- 
ing disease,  or  anaemia.  (4)  It  is  associated  with  parenchyma- 
tous degeneration  in  the  infectious  fevers.  (5)  It  results  from 
mineral  poisoning,  as  by  arsenic,  antimony,  phosphorus. 

Pathology. — The  muscle  is  pale,  soft,  and  flabby,  and 
feels  greasy  to  the  hand.  Microscopic  examination  reveals  a 
deposition  of  granular  fat  in  the  muscle-fibres. 

Symptoms. — When  the  condition  is  marked,  it  is  charac- 
terized by  all  the  symptoms  of  heart-failure,  namely,  dys- 
pnoea, asthma,  cough,  a  weak,  irregular  pulse,  which  may  be 
quite  rapid  or  unusually  slow,  poor  digestion,  weak  heart- 
sounds,  a  feeble  apex-beat,  dropsy,  attacks  of  syncope,  and, 
near  the  end,  Cheyne-Stokes  breathing. 

Disturbed  innervation  often  causes  palpitation,  prsecordial 
distress,  and  attacks  of  angina  pectoris. 

There  may  be  associated  evidences  of  atheroma,  namely, 
rigid  arteries,  and  in  the  cornea,  a  fatty  arcus  senilis. 

Prognosis. — Unfavorable.  Death  may  occur  suddenly  on 
slight  exertion. 

Treatment. — Rest  of  mind  and  body.  A  carefully-i-egu- 
lated   diet,    which    should   be    light   but    nutritious.      Iron, 


ANGINA   PECTOEIS.  147 

quinine,  and  arsenic  are  sometimes  indicated.  In  this  condi- 
tion strychnine  (gr.  gig- 3L  thrice  daily)  is  often  of  great  value. 
Nitro-glycerine  (.gr.  y^u  or  one  minim  of  the  one  per  cent, 
thrice  daily)  may  relieve  the  distressing  symptoms.  Restless- 
ness, prsecordial  distress,  and  insomnia  will  call  for  morphine. 
In  angina,  hot  applications  should  be  applied  to  the  prsecor- 
dia,  and  nitrite  of  amyl  administered  by  inhalation. 

ANGIHA  PECTORIS. 

(Neuralgia  of  the  Heart,  Stenocardia.) 

Definition.  —  A   paroxysmal   aifection  characterized   by' 
severe  pain  radiating  from  the  heart  to  the  shoulder,  thence 
down  the  arm  ;  by  great  anxiety,  and  fixation  of  the  body,  and 
apparently  dependent  upon  some  lesion  of  the  cardiac  arteries, 
walls,  or  valves. 

Etiology. — Male  sex  and  middle  life  are  generally  predis- 
posing factors.  Syphilis,  rheumatism,  gout,  alcoholism,  and 
Bright's  disease  may  lead  to  it  by  inducing  atheroma  of  the 
coronary  arteries. 

The  attacks  may  come  on  without  provocation,  but  eating 
and  excitement,  emotional  or  j^hysical,  usually  induce  them. 
In  some  instances  the  pain  appears  during  sleep. 

Pathology. — Atheroma  of  the  coronary  artery,  fatty  de- 
generation of  the  heart,  and  valvular  lesions  are  the  conditions 
usually  found  after  death.  Their  relation  to  angina  is  still  a 
matter  of  conjecture. 

In  rare  instances,  the  condition  is  probably  a  pure  neurosis, 
for  no  lesions  are  found. 

Symptoms. — Severe  pain  radiating  from  the  prsecordia  to 
the  left  shoulder  and  thence  down  the  arm.  A  sensation  of 
tingling  often  accompanies  the  pain.  There  is  great  anxiety, 
a  fear  of  approaching  death,  and  fixation  of  the  body.  The 
face  is  pale  or  livid,  and  the  brow  bathed  in  sweat.  Dyspnoea 
is  often  noted,  and  the  pulse  is  variable,  being  usually  tense  and 
rapid.  The  duration  of  the  attack  is  from  a  few  seconds  to 
several  minutes. 

Diagnosis.  Gastralgia. — The  pain  does  not  radiate  to 
the  shoulder  and  thence  down  the  arm  ;  there  is  no  fear  of 


^ 


148  DISEASES   OF  THE   CIRCULATORY  SYSTEM. 

approaching  death,  and  no  fixation  of  the  body  ;  the  attaclv 
usually  ai)pears  when  the  stomach  is  empty  ;  there  is  no  evi- 
dence of  organic  heart  disease. 

Pseudo-angina,  or  Hysterical  Angina. — This  affection  oecui-s 
chiefly  in  women  of  a  neurotic  temperament;  is  unassociated 
with  organic  heart  disease ;  usually  occurs  at  night ;  rarely 
induces  fixation  of  the  body ;  is  of  longer  duration  than  true 
angina ;  and  is  associated  with  emotional  excitement. 

Prognosis. — Grave.     Sudden  death  is  to  be  expected. 

The  duration  is  often  long,  and  in  some  instances  recovery 
follows.  The  prognosis  is  more  favorable  when  the  paroxysms 
are  mild,  infrequent,  unassociated  with  organic  lesions,  and 
brought  on  by  exertion. 

Treatment.  Tlie  Attach. — Inhalation  of  nitrite  of  amyl 
(a  few  drops  on  a  handkerchief)  and  hot  applications  to  the 
praecordia.  If  prompt  relief  does  not  follow,  morphine  sul- 
phate (gr.  ^)  wdth  atropine  sulphate  (gr.  ytq)  '^^^J  ^^  given 
hypodermically. 

The  Interval. — Rest  of  body  and  mind.  A  carefully-regu- 
lated diet,  which  should  be  light  but  nutritious. 

Iodide  of  potassium  (gr.  x  thrice  daily)  over  a  long  course 
has  been  highly  recommended. 

Nitroglycerine  (gr.  y^g-  to  J^)  when  well  borne  is  some- 
times extremely  useful  in  warding  off  the  attacks.  Patients 
may  be  provided  with  glass  capsules  of  nitrite  of  amyl. 
General  tonics,  like  strychnine,  iron,  and  arsenic,  are  often  indi- 
cated. 

AJVEURISM  OF  THE   AORTA. 

Definition. — A  circumscribed  dilatation  of  the  aorta. 

Etiology. — The  male  sex,  middle  life,  and  laborious  work 
are  general  predisposing  factors.  The  conditions  which  lead 
to  arterial  degeneration,  like  syphilis,  rheumatism,  gout,  and 
alcoholism,  are  potent  predisposing  causes. 

Sudden  exertion  is  commonly  the  exciting  cause. 

Pathology. — Aneurisms  are  divided  according  to  shape 
into  the  fusiform,  saccular,  and  cylindrical  forms.  AVhen  all 
the  arterial  tunics  have  yielded,  the  dilatation  is  termed  a  true 


ANEURISM   OF   THE   AORTA.  149 

aneurism  ;  when  the  internal  tunic  alone  has  ruptured,  and 
blood  has  escaped  between  the  layers,  it  is  termed  a  false  or 
dissecting  aneurism. 

A  true  aneurism  is  composed  (1)  of  an  external  or  adven- 
titious sac  which  results  from  inflammation  and  condensation 
of  tlie  surrounding  connective  tissue;  (2)  of  one  or  more' of 
the  degenerated  coats  of  the  vessel ;  and  (3)  of  a  clot,  which  is 
often  firm  and  laminated. 

The  arch  of  the  aorta  is  the  most  common  seat.  About  ten 
per  cent,  of  aortic  aneurisms  are  abdominal. 

Thoracic   Aneurism. 

Physical  Signs.  Inspection. — This  often  detects  an  abnor- 
mal prominence  and  pulsation  in  tlie  upper  sternal  region. 

Dilatation  of  the  superficial  veins  may  also  be  noted,  and 
in  advanced  cases  the  skin  over  the  prominence  may  be  red 
and  glossy. 

Palpation. — This  often  detects  an  expansile  j)ulsation  and 
a  systolic  thrill. 

If  the  cricoid  cartilage  is  grasped  between  the  fingers  and 
thumb,  and  drawn  upwards,  a  pulsation  or  tug  may  be  trans- 
mitted to  the  trachea. 

Pereussion. — This  occasionally  reveals  circumscribed  dul- 
ness  and  increased  resistance. 

Auscultation. — If  the  clot  is  not  too  large,  the  ear  may 
detect  a  systolic  bruit  or  murmur.  Accentuation  of  the  heart- 
sounds  is  often  noted. 

Pulse. — The  pulse  in  one  radial  may  be  delayed,  and  dimin- 
ished in  volume  from  the  diffusion  or  spending  of  the  current, 
within  the  sac,  or  from  the  partial  occlusion  of  the  arterial 
orifice. 

Symptoms.  —  Dyspnoea  results  from  pressure  upon  the 
trachea,  bronchi,  or  recurrent  laryngeal  nerve,  the  last  causing 
spasm  or  paralysis  of  the  vocal  cords.  Cough  is  rarely  absent, 
and  when  due  to  spasm  of  the  vocal  cords  it  is  of  a  metallic, 
barking  character. 

Pain  frequently  results  from  pressure  on  the  bones — ver-  ^ 
tebrse  and  sternum,  or  from  irritation  of  neighboring  nerves. 


150  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Dilatation  or  contraction  of  one  j^npil  may  resnlt  from  pres- 
sure on  the  cervical  sympathetic,  and  unilateral  sweating  of  the 
face  is  sometimes  induced  by  the  same  cause. 

Difficult  swallowing  (dysphagia)  results  from  pressure  on 
the  oesophagus ;  and  dilatation  of  the  superficial  veins,  cyano- 
sis,* and  local  oedema  may  result  from  pressure  upon  the  deep- 
seated  veins. 

Diagnosis. — A  solid  tumor  may  yield  a  transmitted  pulsa- 
tion and  simulate  aneurism,  but  in  the  former  the  pulsation  is 
up  and  down,  not  expansile,  the  impact  is  less  pronounced, 
the  bruit  is  usually  absent,  the  heart-sounds  are  not  accentu- 
ated, there  is  no  tracheal  tug,  and  the  health  is  generally  more 
impaired. 

Puhating  Empyema. — A  left-sided  purulent  effiision  may 
transmit  a  cardiac  pulsation,  but  the  latter  is  not  expansile, 
the  duluess  is  diifuse,  the  bruit  is  absent,  and  the  history  will 
suggest  pleurisy. 

An  expansile  aorta  may  simulate  aneurism.  This  condi- 
tion usually  occurs  in  Avomen  of  a  neurotic  temperament,  and 
lacks  the  bruit  and  pressure-symptoms. 

Prognosis. — Always  grave.  The  average  duration  is  from 
one  to  two  years.  Death  may  result  (1)  from  rupture  exter- 
nally, or  internally  into  the  pericardiimi,  heart,  pleural  sac, 
bronchi,  lung,  or  oesophagus ;  (2)  from  exhaustion ;  (3)  from 
heart-failure,  for  sometimes  the  aneurism  dilates  the  aortic  ori- 
fice and  thereby  causes  aortic  insufficiency. 

Treatment. — Mechanical  treatment  by  ligation  of  distal 
arteries,  acupuncture,  and  electrolysis,  has  not  only  been  un- 
satisfactory, but  has  often  shortened  life. 

The  treatment  commonly  employed  is  a  modification  of 
Tufnell's  method,  and  consists  in  absolute  rest  in  bed  for  from 
eight  to  twelve  weeks,  with  a  dry  diet,  and  the  administration 
of  iodide  of  potassium,  which  is  used  empii'ically  in  doses  of 
ten  to  twenty  grains,  thrice  daily.  When  the  pulse  is  very 
strong,  heart  sedatives  like  aconite  and  veratrum  viride  may 
be  administered,  or  venesection  cautiously  practised.  Pain  is 
often  temporarily  relieved  by  the  iodide,  but  wdien  it  is  severe 
an  ice-bag  may  be  applied  locally  and  morphine  given  hypoder- 
mically. 


AETERIO-SCLEEOSIS.  151 

Aueiirlsm  of  the  Abdominal  Aorta. 

Seat. — It  is  most  frequently  located  near  the  coeliac  axis. 

Symptoms. — It  may  be  recognized  by  sharp  pain  in  the 
back,  radiating  along  the  spinal  nerves,  and  increased  by  eat-> 
ing  and  drinking,  by  a  delay  in  the  femoral  pulse,  by  gastro- 
intestinal symptoms,  and  by  physical  signs  similar  to  those  of 
thoracic  aneurism. 

Diagnosis. — An  abdominal  cancer  may  receive  a  pulsation 
from  the  aorta,  and  simulate  aneurism,  but  in  the  former,  pul- 
sation is  not  expansile,  and  is  frequently  lost  when  the  patient 
is  placed  in  the  knee-breast  posture ;  and  there  is  greater 
cachexia,  and  gastro-intestinal  disturbance. 

The  pulsating  aorta  of  nervous  women  may  simulate  aneu- 
rism, but  there  are  no  pressure-symptoms,  or  distinct  tumor, 
and  it  is  in  the  sex  in  which  abdominal  aneurisms  are  very  un- 
common. 

Peognosis. — Very  grave.  Death  usually  results  from 
rupture.  s 

Teeatment. — Same  as  in  thoracic  aneurism.  Compression 
of  the  aorta,  the  patient  having  been  anaesthetized,  has  given 
good  results. 

ARTERIO-SCLEROSIS. 

(Atheroma,  Gull  and  Sutton's  Disease.) 

DEFiNiTiOiSr. — A  thickening  of  the  arteries  due  to  an  over- 
growth of  connective  tissue,  associated  with  more  or  less  fatty 
degeneration  and  calcification. 

Etiology. — Old  age,  gout,  rheumatism,  alcoholism,  syph- 
ilis, lead-poisoning,  nephritis,  and  laborious  work  are  predis- 
posing causes. 

Pathology. — The  arteries  are  thickened,  tortuous,  and 
rigid.  The  intima  reveals  roughened  and  opaque  areas,  Avhich 
are  often  the  seat  of  calcareous  deposits.  In  extreme  cases 
there  may  be  spots  of  necrotic  softening  in  the  subendothelial 
tissue,  forming  "  atheromatous  abscesses."  Microscopic  ex- 
amination shows  more  or  less  fatty  degeneration  of  the  diiferent 
coats,  and  an  overgrowth  of  connective  tissue  in  the  intima. 


152  DISEASES   OF   THE   CIRCULATORY  SYSTE]^!. 

Symptoms,  Circulatory  Phenomena. — Rigidity  of  the  pe- 
ripheral vessels,  a  sluggish,  high-tensiou  pulse,  accentuation  of 
the  second  aortic  sound,  palpitation,  dyspncea,  angiuoid  pains, 
and  liypert'rophj  of  the  left  ventricle. 

Renal  Phenomena. — The  urine  is  increased  in  quantity,  is 
pale  in  color,  and  of  low  specific  gravity.  It  may  contain  a 
trace  of  albumin  aud  a  few  hyaline  casts. 

Cerebral  Phenomena. — Headache,  vertigo,  disturbed  sleep, 
failure  of  memory,  and  tinnitus  aurium. 

Sequels. — Cerebral  congestion,  apoplexy,  fatty  heart,  di- 
latation of  the  heart,  angina  pectoris,  aneurism,  interstitial 
\  nephritis,  gangrene  of  the  extremities. 

Treatment. — A  careful  regulation  of  the  habits,  clothing, 
and  diet.  Stimulants  must  be  avoided.  Iodide  of  potassium 
(gr.  V  thrice  dailv)  has  been  recommended  for  its  absorbent 
effect.  Nitroglycerine  is  sometimes  valuable  in  overcoming 
the  high  arterial  tension. 


DISEASES 


RESPIRATORY  SYSTEM 


THE  NOSE. 


The  Red  Nose. — A  nose  which  is  permanently  and  uni- 
formly red  generally  indicates  alcoholism  or  acne  rosacea.  A 
nose  which  is  permanently  red  and. swollen  at  the  extremities, 
and  has  a  broadened  bridge,  indicates  chronic  hypertrophic 
rhinitis. 

Flattening  of  the  Bridge. — This  may  result  from  trauma- 
tism or  tertiary  syphilis. 

Movement  of  the  Alse  Nasi  during  Respiration. — Playing 
of  tlie  al?e  is  occasionally  noted  in  health,  but  it  is  generally 
an  indication  of  some  obstruction  to  the  entrance  of  air.  It  is 
frequently  observed  in  spasmodic  croup,  true  croup,  laryngeal 
oedema,  capillary  bronchitis,  and  pneumonia. 

Nasal  Discharge. — Temporary  "running  from  the  nose"  is 
a  symptom  of  acute  coryza,  measles,  hay-fever,  diphtheria, 
and  influenza.  An  offensive  discharge  should  suggest  nasal 
diphtheria,  or  the  impaction  of  a  foreign  body. 

Chronic  discharge  occurs  in  chronic  rhinitis.  In  infants, 
chronic  nasal  discharge  with  mouth-breathing  ("  snuffles")  is 
very  suggestive  of  hereditary  syphilis. 

The  Sense  of  Smell. — This  is  tested  by  holding  odoriferous 
substances  before  one  nostril  at  a  time  while  the  other  is  closed. 
Pungent  vapors  should  be  avoided,  as  the  irritation  which 
they  excite,  and  not  their  odor,  may  lead  to  their  recognition. 

(153) 


154  DISEASES   OF   THE   RESPlRATOEY  SYSTEM. 

The  sense  of  smell  is  imrpcdred  or  lost  (anosmia)  from  : — 

1.  Rhinitis  or  morbid  growths. 

2.  Affections  of  the  anterior  part  of  the  brain,  involving 
the  olfactory  nerves  or  bulbs — as  injury,  tumor,  meningitis. 

3.  Lesions  of  the  olfactory  centres. 

4.  Paralysis  of  the  trigeminal  nerve  (by  inducing  dryness 
of  the  mucous  membrane). 

5.  Old  age. 

An  increase  (hyperosmia)  or  a  "perversion  (parosmia)  of  the 
sense  of  smell  may  occur  in  hysteria,  insanity,  and  as  an  aura 
of  epilepsy. 

Epistaxis. — Hemorrhage  from  the  nose  occurs  under  the 
following  conditions :  (1)  Traumatism.  (2)  Inflammation. 
(3)  Obstructed  circulation — as  in  chronic  heart,  lung,  and  liver 
disease.  (4)  Blood-dyscrasia — as  in  scurvy,  infectious  fevers, 
hseraophilia,  and  purpura.  (5)  Onset  of  fevers,  especially 
typhoid.  (6)  Vicarious  menstruation.  (7)  In  rarefied  atmo- 
sphere, as  in  mountain-climbing.  (8)  Often  without  obvious 
cause. 

THE  LARYINX. 

Spasm  of  the  laryngeal  adductors  is  characterized  by  intense 
dyspnoea  and  occurs  in  spasmodic  croup ;  in  true  croup ;  in 
ulceration  of  the  larynx  ;  in  laryngismus  stridulus ;  in  whoop- 
ing-cough ;  in  tetany  ;  in  hysteria ;  in  hydrophobia  ;  in  the 
laryngeal  crisis  of  locomotor  ataxia ;  when  foreign  bodies  have 
lodged  in  the  larynx ;  and  when  aneurisms  or  mediastinal 
tumors  press  on  the  recurrent  laryngeal  nerve  and  irritate  it. 

Aphonia  or  loss  of  voice  may  occur : — 

1.  In  severe  inflammation  of  the  larynx. 

2.  From  hysteria. 

3.  In  centric  paralysis  of  the  recurrent  laryngeal  nerves,  as 
in  bulbar  palsy  and  in  tumors  of  the  medulla. 

4.  In  peripheral  paralysis  of  the  recurrent  laryngeal  nerve 
caused  by  the  pressure  of  an  aneurism,  mediastinal  tumor,  or 
pericardial  effusion. 

5.  From  prolonged  use  of  the  voice. 

6.  From  the  lodgment  of  foreign  bodies. 

7.  From  cicatricial  stenosis  of  the  larynx. 


EESPIEATION. 


155 


Paralysis  of  the  Laryngeal  Muscles. 


Paralysis  of  all 
of  the  muscles. 


Complete  uni- 
lateral paraly- 
sis. 


Complete  par- 
alysis of  the 
abductors. 

Unilateral  par- 
alysis of  the 
abductors. 

Complete  par- 
alysis of  the 
adductors. 


Causes. 
Hysteria  ;  bulbar  pal- 
sy ;      pressure     upon 
both   vagi  or    spinal 
accessories. 

Pressure  upon  one  re- 
current laryngeal  by 
an  aneurism  or  tu- 
mor. 


Catarrhal  laryngitis; 
bulbar  palsy ;  pres- 
sure on  both  vagi  or 
recurrents ;  hysteria. 

Pressure  on  one  recur- 
rent by  an  aneurisTU 
or  mediastinal  tumor. 

Hysteria ;  laryngitis ; 
prolonged  use  of  the 
voice. 


Symptoms. 
Aphonia, but  no  cough 
or  dyspnoea. 


Voice  weak  and  rough ; 
no  cough  or  dyspncea. 


Voice  quite  natural ; 
inspiratory  stridor 
and  dyspncea;  no 
cough. 

Hoarseness ;  fatigue 
after  moderate  use  of 
the  voice ;  slight  dys- 
pnoea. 

Aphonia,  but  no  cough 
or  dyspncea. 


L.iRYNGOSCOPIC 

Appeaeance. 

The  cords  are  midway 
between  adduction 
and  abduction,  and 
are  motionless  ("  cad- 
averic position"). 

One  cord  is  moder- 
ately abducted  and 
motionless ;  the  other 
is  drawn  beyond  the 
median  line  in  pho- 
nation. 

The  cords  are  near  to- 
gether, and  brought 
still  closer  by  inspi- 
ration. 

One  cord  is  near  the 
median  line,  and  is 
motionless  on  inspi- 
ration. 

Cords  are  open  and 
move  naturally  on 
respiration,  but  are 
motionless  during  at- 
tempted phonation. 


RESPIRATIOIV. 

DyspnoBa. — Dyspnoea  implies  difficult  breathing  with  or 
without  an  increase  in  the  number  of  respirations.  Dyspncea 
which  is  so  severe  as  to  necessitate  a  sitting  posture  is  termed 
orthopnoea.  Dyspnoea  may  occur  on  inspiration,  expiration,  or 
both. 

Dyspnoea  on  expiration  is  chiefly  noted  in  pulmonar}^  emphy- 
sema and  asthma. 

Dyspnoea  on  inspiration,  or  on  both  inspiration  or  expira- 
tion. In  this  form  the  base  of  the  chest  is  retracted  during 
the  violent  inspiratory  efforts. 

Its  chief  causes  are :  (1)  Obstruction  in  the  larynx  from 
spasm,  paralysis,  false  membrane,  oedema,  or  a  foreign  body. 
(2)  Pressure  of  an  aneurism,  tumor,  or  large  glands  upon  the 
trachea,  bronchi,  or  recurrent  laryngeal  nerve.  (3)  Asthma. 
(4)  Diseases  of  the  lungs,  as  pneumonia,  emphysema,  oedema, 
phthisis,  abscess,  and  gangrene.  (5)  Pleural  effusions.  (6) 
Cardiac  disease.  (7)  Paralysis  of  the  muscles  of  respira- 
tion.    (8)  Abdominal  distention.     (9)  Ansemia. 


156  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  number  of  respirations  per  minute.  In  the  healthy 
male  adult  the  number  of  respirations  is  about  18  to  20  per 
minute.  In  women  and  children,  breathing  is  somewhat  more 
rapid.  The  ratio  between  respirations  and  pulse-beats  is  1  to 
4  or  4.5. 

Rcifpid  respirations  are  noted  in  excitement ;  in  pyrexia ;  in 
inflammatory  diseases  of  the  lungs  ;  in  anaemia  ;  in  certain  affec- 
tions involving  the  base  of  the  brain;  in  poisoning  from  certain 
drugs  which  affect  the  respiratory  centre ;  in  hysteria ;  in  painful 
affections  of  the  respiratory  muscles,  as  pleurodynia,  pleurisy. 

Infrequent  respirations  are  observed  in  certain  diseases  of 
the  brain,  as  meningitis,  tumor,  apoplexy;  in  advanced  fatty 
degeneration  of  the  heart ;  in  certain  forms  of  coma,  ]3articularly 
ursemic  and  diabetic;  in  poisoning  with  certain  drugs,  espe- 
cially opium ;  in  obstruction  to  the  air-passages,  as  in  asthma 
and  in  laryngeal  spasm. 

Clieyne-StokeSj  or  tidal-wave  breathing.  In  this  type  the 
respirations  gradually  increase  in  rapidity  and  volume  until 
they  reach  a  climax,  then  gradually  subside  and  fiually  cease 
entirely  for  from  five  to  fifty  seconds,  when  they  begin  again. 
It  depends  on  some  disturbance  of  the  respiratory  centre  the 
exact  nature  of  which  is  still  undetermined.  It  is  usually  a 
forerunner  of  death,  but  cases  have  been  reported  in  which  it 
has  lasted  several  mouths. 

Its  chief  causes  are :  (1)  Certain  cerebral  diseases,  as  apo- 
plexy, meningitis,  and  tumor.  (2)  Advanced  cardiac  disease, 
especially  fatty  degeneration.  (3)  Certain  forms  of  coma,  espe- 
cially that  produced  by  urseraia,  opium-poisoning,  and  sun- 
stroke. 

COUGH. 

Cough  results  from:  (1)  All  diseases  of  the  lungs  and 
bronchi.  (2)  Many  diseases  of  the  larynx.  (3)  Foreign 
bodies  in  the  air-passages.  (4)  Certain  infectious  diseases, 
most  of  which,  however,  are  associated  with  catarrh,  as  whoop- 
ing-cough, measles,  influenza,  (5)  Inhalation  of  irritating 
vapors  or  gases.  (6)  Reflex  causes,  such  as  pressure  on  the 
recurrent  laryngeal  nerve  by  an  aneurism,  and  uterine  and 
gastro-intestinal  affections.     (7)  Hysteria. 


EXPECTORATION.  157 

Laryngeal  Cough. — This  cough  has  a  hard,  metallic,  ringing 
intonation,  and  has  been  termed  "cronpy".  It  is  observed  in 
laryngitis ;  in  whooping-cough  ;  in  tuberculosis  and  syphilis  of 
the  larynx ;  when  a  foreign  body  has  lodged  in  the  larynx ; 
when  au  aneurism  or  mediastinal  tumor  presses  on  the  recur- 
rent laryngeal  nerve,  and  irritates  it ;  and  in  hysteria. 

Dry  Cough. — Cough  without  expectoration  is  esjaecially  ob- 
served in  the  beginning  of  inflammatory  diseases  of  the  bronchi 
and  lungs ;  in  pleurisy  ;  in  most  chest  diseases  of  early  child- 
hood ;  and  in  the  reflex  variety 

Moist,  or  loose  cough  occurs  in  bronchitis,  bronchiectasis, 
convalescent  pneumonia,  and  phthisis. 

EXPECTORATION. 

Mucoid  sjnitum  is  noted  especially  in  the  beginning  of  acute 
bronchitis ;  in  asthma ;  in  the  early  stage  of  pneumonia  ;  and 
in  pulmonary  oedema.     In  the  last  it  is  very  frothy  and  watery. 

Muco-purulent  Sputum. — This  is  observed  in  subacute  and 
chronic  catarrhal  affections  of  the  lungs  and  bronchi,  espe- 
cially in  chronic  bronchitis,  convalescent  pneumonia,  and 
phthisis. 

Purulent  Sputum. — Sputum  is  rarely  composed  of  pure  pus. 
Expectoration  almost  entirely  purulent  is  observed  in  bron- 
chiectasis, in  phthisis  with  cavities,  in  abscess  of  the  lung, 
and  when  an  empyema  ru])tures  into  the  lung. 

Prune-juice   Sputum. — Expectoration    tinged    with    altered 
blood  so  as  to  resemble  prune-juice.     It  results  from  reten- 
tion of  the  blood  in  the  lung,  and  is  observed  in  advanced 
croupous  pneumonia,  especially  low  forms,  in  gangrene  of  the . 
lung,  and  in  cancer  in  the  lung. 

Rusty  Sp>utum. — A  rusty  and  tenacious  sputum  is  strongly 
indicative  of  croupous  pneumonia. 

Sputum  containing  fibrous  shreds  is  observed  in  membra- 
nous croup,  in  diphtheria,  and  in  fibrinous  bronchitis. 

Currant-jelly  sputiim  is  indicative  of  cancer  in  the  lungs. 

Fetid  sputum  usually  results  from  bronchiectasis,  advanced 
phthisis  with  cavities,  gangrene  of  the  lung,  and  abscess  of 
the  lung. 


158  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Such  sputum  when  allowed  to  stand  in  a  conical  glass  set- 
tles in  three  layers :  an  upper  layer  of  dirty  froth,  a  middle 
layer  of  turbid  nmcus  in  which  are  suspended  purulent  strings, 
and  a  bottom  layer  of  decomposed  pus. 

Nummular  Sputum. — Sputum  found  in  rouud,  flat,  coin- 
shaped  masses,  whicli  are  heavy  and  sink  in  water.  This 
sputum  is  observed  in  advanced  phthisis,  in  chronic  bron- 
\  chitis,  and  in  bronchiectasis. 


THE  MICROSCOPY  OF  SPUTUM. 

Elastic  fibres  are  found  in  the  sputum  in  phthisis,  abscess, 
gangrene  of  the  lungs,  and  in  some  cases  of  bronchiectasis. 

Fig.  10. 


Elastic  Fibres. 


The  Detection  of  JElastic  Fibres. — Place  the  sputum  which 
has  collected  during  the  night  in  a  glass  beaker,  and  add  to  it 
an  equal  volume  of  a  solution  of  caustic  soda  (20  grains  to 
the  ounce),  and  boil  over  a  spirit-lamp,  stirring  it  occasionally 
with  a  glass  rod.  As  soon  as  it  boils  pour  into  a  conical  gla,ss, 
and  add  four  or  five  times  the  amount  of  cold  distilled  water. 
Allow  the  mixture  to  stand  for  two  to  three  hours,  and  exam- 
ine the  sediment  as  for  tube-casts.     (Fenwick.) 

Spirals  of  Mucin. — Tightly-coiled  spirals  of  mucin,  which 
probably  represent  moulds  of  the  fine  bronchioles,  were  first 
pointed  out  by  Curschmann  in  the  sputum  of  asthma.  They 
have  also  been  observed  in  the  sputum  of  croupous  pneumonia. 


THE  MICROSCX)PY   OF  SPUTUM. 


159 


Charcot-Leyden's  Crystals. — These  are  small  transparent 
octahedral  crystals,  similar  to  those  found  in  the  blood  of  leu- 
caemia. They  are  observed  especially  in  the  sputum  of  asthma. 
They  have  also  been  noted  in  phthisis,  in  fibrinous  bron- 
chitisj  and  in  acute  bronchitis. 

Fig.  11. 


Charcot-Leyden's  Asthma  Crystals.    (After  Eiegel.) 


Crystals  of  Fatty  Acids. — These  occur  as  fine  needles, 
singly  or  in  bundles,  and  are  often  sharply  curved  near  their 
extremities.  They  are  observed  in  the  sputum  of  chronic 
bronchitis,  of  abscess,  and  of  gangrene  of  the  lungs. 

Crystals  of  Hsematoidin. — These  occur  as  small  yellow 
needles,  rhombic  plates  or  tufts,  and  are  found  in  sputa  which 
contain  altered  blood.  They  may  be  observed  in  abscess, 
gangrene,  and  cancer  of  the  lungs. 

Tubercle  Bacilli. — The  presence  of  tubercle  bacilli  in  the 
sputum  is  an  absolute  proof  of  tuberculosis,  but  a  failure  to 
detect  them  after  one  or  two  examinations  is  no  proof  against 


160  DISEASES   OF   THE    EESPIEATOEY   SYSTE]\r. 

phthisis.  The  bacillus  is  a  fine  rod,  in  length  about  half  the 
diameter  of  a  red-blood  corpuscle,  and  often  slightly  bent  and 
beaded.  Its  detection  depends  on  its  power,  when  stained,  of 
resisting  the  bleaching  effect  of  acids.  To  view  it  successfully, 
a  -l^  oil  immersion  lens  is  required. 

Fig.  12. 


Needles  of  Fatty  Acids.    (After  Striimpell.) 

Gabbetfs  Method. — Select  with  a  clean  needle  one  of  the 
minute  caseous  masses  contained  in  tuberculous  sputum,  spread 
it  out  in  a  very  thin  film  on  a  cover-glass,  dry  in  the  air,  and 
coagulate  the  albumin  in  the  bacteria  by  passing  the  cover- 
glass,  smeared  side  up,  three  times  through  the  flame.  Cover 
the  specimen  with  Ziehl's  carbol-fuchsin  solution  (fuchsin  1, 
alcohol  10,  5  per  cent,  aqueous  solution  of  carbolic-acid  crys- 
tals 90),  and  hold  the  cover-glass  over  the  flame  for  a  few 
minutes  at  such  a  distance  that  steam  is  formed.  Wash  off 
the  excess  of  stain  in  water,  and  couuterstain  by  treating  the 
preparation  for  30  seconds  with  Gabbett's  solution  (methyl- 
blue  2,  sulphuric  acid  25,  water  75).  Again  wash  in  water, 
dry,  and  mount  iu  Canada  balsam.  The  tubercle  bacilli  will 
appear  as  red  rods  iu  a  blue  field. 


PHYSICAL    EXAMINATION    OF    EESPIEATORY   ORGANS.       161 

PHYSICAL  EXAMINATION  OF  THE 
RESPIKATORY  ORGANS. 

Inspection. 

Inspection  determines  the  shape  of  the  chest,  any  unnatural 
prominence  or  depression,  the  amount  of  expansion,  and  any 
inequality  of  expansion. 

Fiar.  13. 


An  Outline  of  the  Normal  Chest. 

Phthisiuoid  Chest. — The  antero-posterior  diameter  is  short ; 
the  thorax  is  long  and  flat ;  the  ribs  are  oblique  ;  the  scapulae 
are  prominent ;  the  spaces  above  and  below  the  clavicles  are 
depressed  ;  and  the  angle  formed  by  the  divergence  of  the  cos- 
tal margins  from  the  sternum  is  very  acute. 

Rachitic  Chest. — This  may  resemble  the  former,  but  usually 
the  sides  are  considerably  flattened,  and  the  sternum  promi- 
nent, so  that  the  term  pigeon-breast  has  been  applied  to  this 
particular  form.  The  sternal  ends  of  the  ribs  are  enlarged  or 
"  beaded,"  and  this  characteristic  has  given  rise  to  the  term 
"  rachitic  rosary."  There  is  often  a  circular  constriction  of 
the  thorax  at  the  level  of  the  xiphoid  cartilage. 

Emphysematous  Chest.  —  In  advanced "  emphysema  the 
thorax  is  short  and  round ;  the  antero-posterior  diameter  is 
often  as  long  as  the  transverse  diameter  ;  the  ribs  are  horizon- 
tal ;  the  angle  formed  by  the  divergence  of  the  costal  margin 
11 


162 


DISEASES   OF   THE   EESPIKATOKY    SYSTEM. 
Fig.  14. 


Eachitic  Chest. 


from  the  sternum  is  very  obtuse  or  quite  obliterated.     The 
term  "  barrel-shaped  chest"  is  applied  to  this  configuration. 


Fig.  15. 


Emphysematous  Chest. 

Local  Prominences  and  Depressions. — An  unnatural  promi- 
nence or  depression  is  often  observed  over  the  lower  part  of 
the  sternum,  and  is  generally  congenital.  The  term  funnel- 
breast  or  shoemaker's-breast  (because  it  may  result  from  the 
pressure  of  tools)  has  been  applied  to  the  sternal  depression. 

A  Unilateral  or  Local  Depression  may  he  due  to:  (1) 
Phthisical  consolidation.  (2)  Cavity.  (3)  Pleurisy  with 
fibrous  adhesions. 

A  Unilateral  or  Local  Prominence  may  he  due  to:  (1) 
Pleurisy   with    eflfusion.      (2)    Pneumothorax,   hydrothorax, 


PHYSICAL    EXAMINATION   OF   EESPIEATOEY   OEGANS.       163 

hsemotborax.  (3)  Au  aneurism  or  tumor.  (4)  Compensatory 
emphysema,  resulting  from  impairment  of  the  opposite  lung. 
(5)  Cardiac  enlargements  (left  side).  (6)  Enlargements  of 
the  abdominal  organs,  especially  the  liv^er  and  spleen. 

Expansion. — In  women  and  in  children,  breathing  is  largely 
thoracic,  or  costal ;  in  men  and  in  the  old  of  both  sexes,  it  is 
largely  abdominal,  or  diaphragmatic. 

Restricted  abdominal  breathing  is  observed  in  pregnancy,  in 
abdominal  tumors  and  effusions  ;  in  peritonitis  ;  in  diaphrag- 
matic pleurisy  ;  in  paralysis  of  the  phrenic  nerve  from  pressure 
or  from  bulbar  disease ;  and  occasionally  in  the  "  hysterical 
abdomen." 

Palpation. 

Palpation  serves  to  detect  any  thoracic  tenderness,  oedema, 
friction-fremitus,  or  rRles,  and  to  determine  the  vocal  fremitus 
and  amount  of  expansion. 

Thoracic  tenderness  is  observed  iu  pleurisy ;  in  phthisis, 
and  pneumonia  from  being  associated  with  pleurisy  ;  in  pleuro- 
dynia ;  in  intercostal  neuralgia  (confined  to  certain  spots)  ; 
and  in  surgical  affections,  like  caries  and  fracture  of  the  ribs ; 
and  in  contusion  and  inflammation  of  the  parietes. 

(Edema  of  the  chest  walls  is  recognized  by  "  pitting"  when 
pressure  is  made  with  the  finger.  It  may  be  observed  in  em- 
pyema ;  in  deep-seated  abscesses  of  the  parietes ;  after  the 
application  of  a  blister;  and  in  general  dropsy. 

Friction-fremitus  and  Rales. — The  friction-sound  of  pleu- 
risy and  harsh  sonorous  rales  can  sometimes  be  detected  by 
palpation. 

Vocal,  or  Tactile  Fremitus. — The  transmission  of  the  vibra- 
tions of  the  voice  to  the  hand. 

In  determining  the  vocal  fremitus  observe  the  following  pre- 
cautions :  Palpate  symmetrical  parts  of  the  chest ;  make  firm 
pressure ;  when  comparing  use  the  same  pressure  on  the  two 
sides;  apply  the  hands  as  nearly  parallel  to  the  ribs  as 
possible  ;  and  remember  that  the  fremitus  is  normally  in- 
creased over  the  right  apex. 


164  DISEASES   OF   THE    EESPIEATORY   SYSTEM. 

Vocal  fraiutm  is  increased  in :  (1)  Phthisical  consolidation. 
(2)  Pneumonic  consolidation. 

Vocal  fremitus  is  decreased  in :  (1)  Pleural  eifusions — air, 
pus,  serum,  lymph,  or  blood.  (2)  Emphysema.  (3)  Pulmo- 
nary collapse  from  an  obstructed  bronchus.  (4)  Pulmonary 
oedema.     (5)  Morbid  growths  of  the  lung. 

Percussion. 

Percussion  determines  resonance,  pitch,  and  resistance. 

Immediate  percussion  is  performed  by  striking  the  chest  di- 
rectly with  the  fingers.  It  is  not  often  employed,  except  over 
the  clavicles,  where  the  bones  themselves  act  as  pleximeters. 

Mediate  jjei'cussion  is  performed  by  using  the  fingers  of  one 
hand  as  a  plessor,  and  those  of  the  opposite  hand  as  a  plexi- 
meter  ;  or  by  using  a  piece  of  ivory,  glass,  or  hard  rubber  as  a 
pleximeter,  and  a  small  hammer  as  a  plessor. 

The  use  of  the  fingers  alone  is  preferable,  for  only  in  this 
way  can  resistance  be  determined. 

In  pei'cussion  the  following  precautions  should  be  observed  : 
Place  the  finger  which  is  being  used  as  a  pleximeter  firmly 
against  the  chest,  and  preferably  parallel  to  the  ribs ;  make 
the  finger  which  is  used  as  plessor  strike  the  one  on  the  chest 
perpendicularly  ;  fix  the  forearm,  and  use  no  more  force  than 
can  be  obtained  from  a  gentle  swing  of  the  wrist.  When  pos- 
sible, percuss  all  parts  of  the  chest  anteriorly  and  posteriorly ; 
percuss  both  in  inspiration  and  in  expiration.  In  comparing 
the  two  sides,  be  sure  to  percuss  symmetrical  parts. 

Normal  Resonance. — On  the  right  side,  pulmonary  resonance 
extends  from  a  half  inch  to  an  inch  above  the  clavicle,  down- 
ward to  the  upper  border  of  the  sixth  ril>  in  front,  and  to  a  line 
drawn  through  the  tenth  spinous  process  posteriorly. 

On  the  left  side,  pulmonary  resonance  extends  from  a  half 
inch  to  an  inch  above  the  clavicle,  downward,  within  the  mam- 
mary line  to  the  third  rib,  outside  of  the  mammary  line  to  the 
tenth  rib,  and  posteriorly  to  a  line  drawn  through  the  tenth 
spinous  process. 

Hyper-resonance  is  observed  in  the  following  conditions : 
(1)  Pneumothorax.  (2)  Cavities — tuberculous  or  bronchiec- 
tatic.     (3)  Emphysema.     (4)  Lowered  pulmonary  tension  in 


AUSCULTATION.  165 

the  initial  stage  of  pneumonia  and  above  a  pleural  effusion 
(Skoda's  resonance).  (5)  Flatulent  distention  of  the  stomach 
or  colon  (frequently  observed  over  the  left  base). 

A  tympanitic  note  is  a  hollow,  drum-like  sound  like  that 
which  is  normally  obtained  by  percussing  the  larynx  or  empty 
stomach.  The  above  conditions  are  also  capable  of  producing 
tympany. 

The  cracked-pot  sound,  or  hruit  de  pot  feU,  is  a  modified 
tympany,  and  can  be  simulated  by  percussing  over  the  cheek 
when  the  mouth  is  partially  open.  It  may  be  normally  heard 
over  the  chest  of  a  crying  infant  (Walshe).  In  the  adult  it 
usually  indicates  a  cavity  which  has  a  free  communication 
with  a  bronchus.  It  is  l^est  detected  by  keeping  the  ear  near 
the  open  mouth  of  the  patient  while  percussing. 

Dulness  or  flatness  is  recognized  in  the  following  condi- 
tions :  (1)  Phthisical  consolidation.  (2)  Pneumonic  consoli- 
dation. (3)  Pleural  effusions  of  all  kinds,  except  air.  (4)  Col- 
lapse of  the  lung.  (5)  Congestion  and  cedema  of  the  lung. 
(6)  Enlargement  of  the  liver  or  spleen  (at  the  bases).  (7) 
Morbid  growths  in  the  lung. 

Pitch.— Pitch  dejoends  largely  upon  the  volume  of  air,  upon 
the  tension  of  the  walls  of  the  cavity,  and  upon  the  size  of  the ' 
opening  which  communicates  with  the  cavity.  The  less  the  air, 
the  greater  the  tension,  and  the  smaller  the  opening,  the  higher 
Avill  be  the  pitch  of  the  note.  It  is  obvious,  therefore,  that 
conditions  which  are  associated  with  hyper-resonance  may 
yield  either  a  high-  or  a  low-pitched  note.  In  beginning 
phthisical  consolidation,  the  note  over  the  affected  apex  is 
higher  pitched  ;  but  it  must  be  borne  in  mind  that  normally 
the  note  over  the  right  apex  is  higher  pitched  than  that  over 
the  left. 

Resistance. — The  greater  tlie  dulness  the  greater  will  be  the 
resistance  ;  hence  there  is  always  more  resistance  over  a  large 
pleural  effusion  than  ov^er  a  pneumonic  or  phthisical  con- 
solidation. 

Auscultation. 

Auscultation  determines  the  character  of  the  breathing  and 
of  the  vocal  resonance,  and  detects  adventitious  sounds,  like  rales. 


166  DISEASES   OF  THE  EESPIRATOEY  SYSTEM. 

In  immediate  auscultation  the  ear  is  placed  directly  over  the 
chest,  a  soft  towel  only  intervening. 

In  mediate  auscultation  the  sounds  are  transmitted  through 
a  stethoscope,  which  should  be  applied  to  the  bare  chest. 

In  auscultation  observe  the  following  precautions  :  Do  not 
exert  much  pressure  with  the  stethoscope ;  when  the  chest  is 
covered  with  hair  moisten  the  latter,  otherwise  it  will  produce 
friction-sounds  resembling  rales.  When  possible,  auscult  all 
over  the  chest,  anteriorly  and  posteriorly ;  auscult  on  quiet 
breathing,  on  full  inspiration,  on  full  expiration,  and  after 
coughing.  In  comparing  the  two  sides  auscult  symmetrical 
parts. 

Normal  Respiration. — Vesicular  breathing  is  heard  over  the 
body  of  the  lungs,  and  is  characterized  by  a  soft,  breezy  inspi- 
ration and  a  short,  low-pitched  expiration.  Normally,  expi- 
ration is  not  more  than  one-third  as  long  as  inspiration.  Aus- 
cultation over  the  trachea,  or  over  the  main  bronchi  in  the 
interscapular  space,  yields  bronchial  breathing,  i.  e.,  harsh 
breathing  with  prolonged  high-pitched  expiration. 

Modifications  of  the  respiratory  murmur.  Puerile  Breath- 
ing.— This  type  is  heard  normally  over  the  lungs  of  children  ; 
it  is  loud,  and  expiration  is  higher  pitched  than  in  vesicular 
breathing,  and  almost  as  long  as  inspiration. 

Exaggerated  Breathing. — This  type  has  almost  the  same 
peculiarities  as  puerile  breathing,  and  is  heard  over  a  lung 
that  is  doing  extra  work  necessitated  by  some  impairment  of 
its  fellow. 

Bronchial  or  Tubular  Breathing. — Harsh  breathing,  with 
a  prolonged  high-pitched  expiration,  which  has  sometimes  a 
tubular  "quality.  Bronchial  breathing  is  heard  over  :  (1) 
Phthisical  consolidation.  (2)  Pneumonic  consolidation.  (3) 
Lung  which  is  compressed.  (4)  Rarely  over  a  lung  which  is 
infiltrated  with  a  morbid  growth. 

Amphoric  and  Cavernous  Breathing. — These  two  are  almost 
identical;  the  sounds  are  loud,  and  expiration  is  prolonged  and 
hollow.  The  pitch  of  amphoric  breathing  is  a  little  higher 
than  that  of  cavernous.  Amphoric  breathing  may  be  imitated 
by  blowing  over  the  mouth  of  an  empty  jar. 

Amphoric  or  cavernous  breathing  may  be  heard  in  the  fol- 


AUSCULTATION.  167 

lowing  conditions :    (1)  Phthisical  or  bronchi ectatic  cavities. 

(2)  Pneumothorax,  when  the  opening  in  the  lung  is  patulous. 

(3)  Areas  of  consolidation  near  a  large  l)ronchus.     (4)  Some- 
times over  lung  compressed  by  a  moderate  effusion. 

Asthmatic  Breathing. — Harsh  breathing  with  a  prolonged 
wheezing  expiration.  It  may  resemble  bronchial  breathing, 
but,  unlike  the  latter,  it  is  heard  all  over  the  chest. 

The  Breathing  of  Emphysema. — Weak  breathing,  with  pro- 
longed low-pitched  or  inaudible  expiration. 

Cogged-wheel,  or  Jerhy  Breathing. — The  respiratory  murmur 
is  not  continuous,  but  is  broken  into  waves.  It  is  not  indicative 
of  any  special  disease,  but  it  is  frequently  observed  in  bron- 
chitis and  in  incipient  phthisis. 

Weak  or  Shalloiv  Breathing. — This  is  noted  :  (1)  When  the 
chest-walls  are  thick.  (2)  In  the  old  and  feeble.  (3)  In 
emphysema.  (4)  In  pleural  effusion.  (5)  In  incipient 
phthisis.  (6)  In  painful  affections  of  the  chest,  like  pleuro- 
dynia and  beginning  pleurisy.     (7)  In  pulmonary  oedema. 

Vocal  Resonance. — The  vibrations  of  the  voice  transmitted 
to  the  ear. 

Vocal  resonance  is  normally  more  marked  over  the  right 
apex.  It  is  abnormally  increased  in :  (1)  Pneumonic  consoli- 
dation. (2)  Phthisical  consolidation.  (3)  Cavities  which  freely 
communicate  with  a  bronchus. 

Vocal  resonance  is  diminished  or  absent  in:  (1)  Pleural 
effusions — air,  pus,  serum,  lymph,  or  blood.  (2)  Emphysema. 
(3)  Pulmonary  collapse.     (4)  Pulmonary  oedema. 

Bronchophony. — Extreme  exaggeration  of  the  vocal  resonance ; 
the  sounds,  but  not  the  words,  are  transmitted.  It  is  especially 
noted  over  marked  consolidations  and  over  certain  cavities. 

Pectoriloquy. — The  distinct  transmission  of  articulate  speech 
to  the  ear ;  the  words  appear  to  emanate  from  the  spot  which 
is  ausculted. 

Pectoriloquy  is  heard  over  :  (1)  Cavities  which  communicate 
with  a  bronchus.  (2)  Areas  of  consolidation  in  the  neighbor- 
hood of  a  large  bronchus.  (3)  Pneumothorax,  when  the  open- 
ing in  the  lung  is  patulous.     (4)  Some  pleural  effusions. 

JEgophony. — A  modified  bronchophony,  characterized  by  a 
trembling,  bleating  sound.     It  is  usually  heard   over  slight 


168  DISEASES    OF    THE   RESPIRATORY   SYSTEM. 

pleural  effusions  near  the  upper  border  of  dulness,  especially 
near  the  inferior  angle  of  the  scapula. 

It  is  occasionally  heard  in  beginning  pneumonia. 

Adventitious  Sounds.  Rales,  or  Ehonohi, — These  are  abnor- 
mal sounds  which  replace  or  accompany  the  respiratory  murmur. 

C  Vesicular  =  Crepitant. 

I 

Pulmonary  rales    \  f  Sonorous. 

T,         T  1  f       -^      t  Sibilant. 
Bronchial  J  >a   i  -i     ^ 

J_  j  I  iSubcrepitant. 

'^  Moist     \  Bubbling. 

(Gurgling. 

Extra-pulmonary  rales  =  Pleuritic  friction-sounds. 

Crepitant  Btdes. — These  are  very  fine  rales,  and  are  heard  at 
the  end  of  inspiration.  They  may  be  simulated  by  rubbing  a 
lock  of  hair  between  the  fingers.  They  have  been  especially 
associated  with  the  first  stage  of  croupous  pneumonia,  and  it 
has  been  supposed  that  they  were  due  to  the  forcible  separation 
of  adherent  vesicular  walls.  E-ales  very  similar  to,  if  not  iden- 
tical with  tbese,  are  heard  in  capillary  bronchitis  and  in  pul- 
monary oedema. 

Dry  rales  are  probably  produced  by  the  presence  of  viscid 
secretion  in  the  tubes ;  they  have  a  more  or  less  whistling, 
musical,  or  squeaking  intonation.  They  are  heard  particularly 
in  bronchitis  and  asthma.  Sibilant  rales  are  whistling  and 
high  pitched  ;  sonorous  rales  have  a  humming  quality  and  are 
lower  pitched.  Dry  rales  may  be  heard  on  inspiration,  expi- 
ration, or  both. 

Moist  redes  result  from  the  presence  of  liquid  in  the  tubes  ; 
the  thinner  the  liquid  and  the  larger  the  tube,  the  coarser  will 
be  the  rales.  They  may  be  heard  on  inspiration,  expiration, 
or  both. 

Suhcrepitani,  or  crackling  rales  are  fine  moist  rales,  and  heard 
in  all  conditions  which  are  associated  with  liquid  in  the  smaller 
tubes,  as  bronchitis,  capillary  bronchitis,  pulmonary  oedema, 
and  beginning  phthisis. 

Bubbling  rales  are  coarser  than  subcrepitant ;  and  are  heard 
in  bronchitis,  in  resolving  croupous  pneumonia,  over  phthisical 
deposits  which  are  softening,  and  over  small  cavities. 


AUSCULTATION.  169 

Gurgling  rales  are  very  coarse  and  resemble  the  bursting  of 
large  bubbles.  They  are  heard  over  large  cavities  which  con- 
tain fluid,  and  in  the  trachea  in  the  so-called  "  death-rattle." 

Frletion-sounds  are  produced  by  the  rubbing  together  of 
roughened  pleural  surfaces.  They  may  be  heard  both  in  in- 
spiration and  expiration,  and  often  resemble  subcrepitant  rales, 
but  they  are  more  superficial  and  localized  than  the  latter,  and 
are  not  modified  by  cough  or  deep  inspiration. 

A  roughened  pleura  in  the  neigliborhood  of  the  heart  may 
produce  a  friction-sound  of  cardiac  .rhythm,  and  one  which 
will  still  continue  when  the  breath  is  held ;  under  other  condi- 
tions pleural  friction-sounds  cease  when  respiration  is  sus- 
pended. 

Other  Adve7ititlous  Soimds.  3fetallio  TinUing. — This  name 
is  applied  to  silvery  or  bell-like  sounds  which  are  heard  at  in- 
tervals over  a  pneumo-hydrothorax  or  large  cavity.  Speaking, 
coughing,  and  deep  breathing  usually  induce  them.  Care 
must  be  taken  not  to  confound  them  with  similar  sounds  pro- 
duced by  the  presence  of  liquid  in  a  distended  stomach. 

SuGCUsslon-splash,  or  Hippocratic  Succussion. — This  is  a 
splashing  sound  produced  by  the  presence  of  air  and  liquid  in 
the  chest.  It  may  be  elicited  by  gently  shaking  the  patient 
while  auscultating.  It  nearly  always  indicates  either  a  liydro- 
or  a  pyo-pneuinothorax,  although  it  has  been  detected  over 
very  large  cavities. 

Air  and  liquid  in  the  stomach  produce  a  similar  sound. 

Mensuration. 

In  measuring  the  sides  of  the  chest  observe  the  following 
precaution  :  Measure  from  the  middle  of  the  sternum  to  the 
spinous  processes ;  measure  both  sides  after  inspiration  and 
after  expiration  ;  apply  the  tape  with  equal  firmness  to  the  two 
sides.  In  comparing,  measure  corresponding  levels,  and  re- 
member that  the  right  side  is  from  half  an  inch  to  an  inch 
greater  in  circumference  than  the  left. 

The  conditions  which  render  one  side  more  prominent  than 
the  other  have  already  been  considered. 


170  DISEASES   OF  THE   RESPIRATORY  SYSTEM. 


CORYZA. 

(Acute  Rhinitis,  Cold  in  the  Head.) 

Definition. — An  acute  inflamaiation  of  the  nasal  cavities. 

Etiology. — Exposure  to  cold  drafts  and  to  wet,  especially 
when  the  body  is  overheated,  is  a  common  cause.  It  may  be 
excited  by  the  inhalation  of  irritating  vapors  or  dust.  It  is 
an  expression  of  iodism.  It  is  a  symptom  of  certain  infectious 
diseases — especially  syphilis,  measles,  and  influenza. 

Pathology. — The  mucous  membrane  is  red  and  swollen. 
In  the  first  stage  there  is  no  secretion,  but  later  irritating, 
watery  mucus  flows  from  the  nose  and  excoriates  the  lip ;  this 
in  time  is  followed  by  a  copious  muco-purulent  discharge. 

Symptoms.  —  The  disease  is  ushered  in  with  chilliness, 
malaise,  fulness  in  the  head,  and  sneezing.  The  nasal  cham- 
bers are  obstructed,  so  that  the  patient  is  obliged  to  breathe 
through  his  mouth.  At  first  there  is  no  secretion,  but  in 
twenty-four  or  forty-eight  hours  a  watery  discharge  is  estab- 
lished, which  later  becomes  muco-purulent.  Slight  fever  and 
its  associated  symptoms  are  commonly  present.  The  duration 
is  from  a  few  days  to  two  we'eks. 

Complications. — The  disease  is  often  accompanied  with 
conjunctivitis,  pharyngitis,  laryngitis,  and  catarrh  of  the 
Eustachian  tube  and  middle  ear  which  results  in  temporary 
deafness. 

Prognosis. — Favorable. 

Treatment. — In  the  early  stage  a  cold  in  the  head  can 
frequently  be  aborted  by  the  use  of  hot  drinks,  a  laxative, 
moderate  doses  of  quinine,  and  the  application  of  menthol  to 
the  nasal  chambers.  Some  crystals  of  menthol  may  be  placed 
in  a  wide-mouth  bottle,  and  their  vapor  inhaled  for  from  ten 
to  twenty  minutes  several  times  during  the  day.  A  spray  of 
menthol  may  be  employed  : — 

]^  Menthol,  ^j  ; 

01.  amygd.  dulcis,  vel  benzoiual,  f^iij. — M. 
Sig. — Spray  into  the  nose  several  times  daily. 


CHEONIC  NASAL  CATARRH.  171 

Cocaine  is  often  efficient  in  allaying  the  fulness  and  distress; 
a  four  per  cent,  solution  may  be  applied  to  the  nose  on  a 
pledget  of  cotton  or  by  means  of  a  camel's-hair  brush. 

When  the  symptoms  are  severe  Dover's  powder  (gr.  v)  may 
be  given  in  combination  with  quinine  (gr.  v)  thrice  daily. 

CHRONIC  NASAL  CATARRH. 

(Chronic  Rhinitis.) 

Definition. — A  chronic  inflammation  of  the  nasal  mucous 
membrane,  characterized  by  increased  secretion  and  impair- 
ment of  the  sense  of  smell. 

Etiology. — Repeated  attacks  of  acute  coryza,  impure  air, 
the  continual  inhalation  of  irritating  dusts  or  vapors,  lowered 
vitality,  and  congenital  or  acquired  obstruction  of  the  nasal 
chambers  are  causal  factors.  It  is  also  an  expression  of 
syphilis. 

Varieties. — Two  varieties  have  been  recognized  :  Chronic 
hypertrophic  rhinitis  and  chronic  atrophic  rhinitis. 

Hypertrophic  Rhinitis.  Symptoms. — A  thick  mucous  dis- 
charge from  the  nose;  great  liability  to  attacks  of  acute 
coryza ;  obstruction  of  one  or  both  nasal  cavities,  causing 
mouth-breathing ;  a  nasal  intonation  of  the  voice ;  frontal 
headache  ;  and  impairment  of  the  sense  of  smell. 

Symptoms  of  catarrh  of  the  neighboring  organs  are  fre- 
quently present.  The  most  common  of  these  are  :  dryness  of 
the  throat  and  hawking  from  pharyngitis ;  deafness  from 
catarrh  of  the  middle  ear ;  and  watering  of  the  eyes  from  catar- 
rhal occlusion  of  the  lachrymal  canal. 

Inspection. — The  bridge  of  the  nose  is  frequently  flattened, 
and  the  alee  are  thickened  and  red ;  the  mucous  membrane  is 
red  and  the  cavities  are  more  or  less  occluded  from  hyper- 
trophy of  the  cavernous  tissue  covering  the  turbinated  bones. 
In  advanced  cases  exostoses  from  the  bony  framework  are 
sometimes  noted. 

Prognosis. — Under  judicious  and  persistent  treatment  the 
aflection  is  curable. 

Treatment. — The  naso-pharynx  must  be  kept  clean  by 


172  DISEASES   OP   THE    RESPIRATORY   SYSTEM. 

means  of  antiseptic  douches  or  sprays;  Dobell's  solution  (see 
page  31)  or  the  following  may  be  emjiloyecl  for  this  purpose: — 

R     Sodii  boratis, 

Sodii  bicarbonatis,  aa  5ss  ; 

Sodii  benzoatis, 

Sodii  salicylatis,  aa  <rr.  ij  ; 

Sodii  chloridi,  gr.  vij  ; 

Eiicalyptol,  thymol,  aa  gr.  j  ; 

Menthol,  gr.  ss; 

Olei  gaultheria?,  gtt.  j  ; 

Glycerini,  f.^ss ; 

Alcoholis,  i'3j ; 

AqufB,  q.s.  ad  Oj. — M. 

Mild  astringent  sprays  are  often  useful,  and  sulphate  of 
zinc  or  sulphate  of  copper  (five  to  ten  grains  to  the  ounce)  may 
be  employed  for  this  purpose. 

Tonics  like  cod-liv^er  oil,  hypophosphites,  iron,  arsenic,  and 
strychnia  are  often  indicated. 

To  eifect  a  cure  the  naso-pharynx  nnist  be  unobstructed ; 
hypertrophies  and  exostoses  must  be  removed  and  deviations 
of  the  septum  corrected  by  surgical  means. 

Atrophic  Rhinitis.  {Ozcena)  Symptoms. — A  sense  of  dry- 
ness in  the  nose  and  throat ;  a  thick  purulent  discharge,  or  the 
expulsion  of  discolored  crusts  ;  an  oifensive,  ]iutrid  odor,  which 
has  given  rise  to  the  term  Oz?ena;  impairment  of  the  sense 
of  smell.  The  general  health  is  always  poor;  such  patients 
are  usually  thin  and  anaemic. 

Inspection. — The  chambers  are  large;  the  mucous  membrane 
is  pale,  dry,  and  glazed  ;  adherent  scabs  are  generally  present. 
In  advanced  cases,  ulceration  and  necrosis  are  observed. 

Prognosis. — Perfect  cure  is  rarely  obtainable ;  but  treat- 
ment may  effect  great  improvement. 

Treatment. — Crusts  must  be  removed  and  the  nasal 
chambers  kept  clean  with  antiseptic  sprays  or  douches.  Stim- 
ulating ap])Hcations  are  useful,  and  solutions  of  nitrate  of 
silver,  sulphate  of  iron,  or  sulphate  of  zinc  may  be  employed. 
A  30  per  cent,  solution  of  lactic  acid  is  also  recommended. 
Ebstein  uses  tampons  soaked  in  balsam  of  Peru.  When  there 
is  much  jHu-ulent  discharge  a  20  per  cent,  mixture  of  ichthyol 
in  cosmoline  is  very  eflficient.  General  tonics  like  cod-liver 
oil,  hypophosphites,  iron,  arsenic,  etc.  are  indicated. 


ACUTE   CATAEEHAL,   LiARYNGlTIS.  173 

ACUTE  CATARRHAL  LARYNGITIS. 

Definition. — An  acute  catarrhal  inflammation  of  the 
larynx,  characterized  by  hoarseness,  hard  cough,  and  painful 
deglutition. 

Etiology. — Improper  use  of  the  voice  ;  exposure  to  cold 
and  wet ;  the  inhalation  of  irritating  dusts  or  vapors ;  the  im- 
paction of  foreign  bodies  are  its  common  causes.  It  is  also  an 
associated  condition  in  certain  infectious  diseases,  like  whoop- 
ing-cough, measles,  diphtheria,  and  influenza. 

Pathology. — The  mucous  membrane  is  red,  swollen,  and 
injected. 

In  grave  cases  the  tissues  may  be  markedly  oedematous. 

Symptoms. — Hoarseness  of  the  voice  or  aphonia  ;  hard, 
ringing  cough ;  pain  in  the  throat  increased  by  speaking, 
coughing,  and  swallowing  ;  expectoration,  which  is  first  scanty 
and  later  muco-purulent ;  fever  and  its  associated  symptoms. 
In  sensitive  people,  and  especially  in  children,  paroxysms  of 
croupy  cough  and  dyspnciea  (false  croup)  may  result  from 
spasm  of  the  vocal  cords  ;  and  when  there  is  much  oedema, 
dyspnoea  or  asphyxia  will  be  a  prominent  feature. 

Inspection. — The  mucous  membrane  of  the  laryngeal  walls 
and  vocal  cords  is  red  and  swollen.  In  grave  cases  the  tissues 
are  highly  oedematous. 

Peognosis. — In  simple  laryngitis  Avithout  oedema  the  prog- 
nosis is  altogether  favorable.  The  attack  usually  lasts  from 
a  week  to  ten  days.  When  there  is  oedema  of  the  larynx, 
indicated  by  dyspnoea  or  asphyxia,  the  prognosis  is  grave. 

Teeatment. — The  patient  should  be  confined  to  his  room 
and  preferably  to  bed.  The  temperature  of  the  room  should 
be  70°  or  75°,  and  the  atmosphere  should  be  moistened  by  the 
-generation  of  steam. 

Iodine,  or  in  severe  cases  an  ice-bladder,  should  be  applied 
to  the  throat.  The  inhalation  of  medicated  vapors  is  decidedly 
useful,  and  one  of  the  following  may  be  employed  :  Lime- 
water,  Dobell's  solution,  wine  of  ipecac  (diluted  with  two 
volumes  of  water),  or  the  menthol  mixture  mentioned  in  the 
treatment  of  acute  coryza. 


174  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Internal  Treatment. — A  saline  laxative  may  be  administered 
at  the  beginning,  and  followed  by  one  of  the  following  seda- 
tive mixtures :  Dover's  powder  (gr.  v)  with  quinine  (gr.  v) 
thrice  daily,  or  : — 

^  Potassii  citratis, 

Potassii  bromid.,  aa  ^ij  ; 
Aporaorph.  hj'drochlor. ,  gr.  h  ; 
Aqufe  et  syr.  sarsaparillfe  comp.,  aa  f^iss— M. 
Sig. — A  teaspoonful  every  two  hours  to  a  child  of  five  years. 

Or — One  of  the  following  tablets  devised  by  Dr.  Seller  : — 

^L  Potass,  chlor., 

Potass,  bromid., 

Pulv.  ext.  glycyrrhiz8e,  aa  gj  ; 

Tiuct.  ferri  chlor.,  f^ss  ; 

Sacchar.,  etc.,  q.  s.— M. 
Ft.  in  trochisci  No  xx. 
Sig. — One  every  three  or  four  hours. 

Qildema  of  the  larynx,  indicated  by  extreme  dyspnoea,  will 
require  scarification  of  the  mucous  membrane  or  tracheotomy. 


CHRONIC  LARYNGITIS. 

Simple  Cliroiiic  Catarrhal  Laryngitis.  Symptoms. — Tick- 
ling in  the  throat,  huskiness  of  the  voice,  fatigue  and  pain 
after  moderate  use  of  the  voice,  and  the  expectoration  of  viscid 
mucus  are  the  usual  symptoms. 

LaryngoscopiG  examination  reveals  redness  of  the  mucous 
membrane  and  sometimes  slight  ulcerations. 

Treatment. — The  patient  must  learn  to  use  the  voice 
properly ;  sounds  must  be  expelled  by  the  abdominal  muscles 
and  diaphragm,  and  not  by  the  muscles  of  the  throat.  Flan- 
nel protectors  should  be  avoided,  and  the  application  of  cool 
water  to  the  neck,  night  and  morning,  instituted  in  their  stead. 
Tonics  are  generally  indicated.  Expectorants  which  are  elim- 
inated by  the  respiratory  mucous  membrane  are  useful ;  and 
one  of  the  following  may  be  employed  :  Terebeue  (gtt.  v  on 
sugar),  oleoresin  of  cubebs  (gtt.  x-xx  on  sugar),  oil  of  euca- 
lyptus (gtt.  V  in  capsule). 


CHRONIC   LARYNGITIS.  175 

Topical  Treatment. — A  faradic  current  to  the  neck  is  often 
beneficial ;  medicated  solutions  should  be  applied  to  the  larynx 
by  means  of  a  brush  or  atomizer.  The  following  are  the 
remedies  commonly  employed :  Nitrate  of  silver,  chloride  of 
ammonium,  chlorate  of  potassium,  sulphate  of  zinc,  and  tinc- 
ture of  benzoin. 

Tuberculous  Laryngitis. — This  is  nearly  always  secondary 
to  pulmonary  tuberculosis,  but  it  occasionally  occurs  as  a  pri- 
mary affection. 

Symptoms. — Hoarseness  of  the  voice  or  aphonia ;  pain  in 
the  throat  increased  by  coughing,  speaking,  or  swallowing ; 
and  hacking  cough  are  the  usual  symptoms. 

Laryngoscopic  Examination. — The  mucous  membrane  is 
pale  and  thickened ;  the  arytenoid  cartilages  are  considerably 
swollen  ;  small,  irregular,  shallow  ulcers  with  gray  bases  are 
frequently  noted,  particularly  in  the  inter-arytenoid  space. 

Treatment. — Remedies  must  be  directed  to  the  primary 
pulmonary  disease.  Local  applications  are  required  to  relieve 
the  pain.  Powders  of  iodoform  or  morphine  may  be  dusted  on 
the  ulcers,  or  a  solution  of  nitrate  of  silver,  of  cocaine,  or  of 
menthol  may  be  applied  by  means  of  a  laryngeal  brush. 

Syphilitic  laryngitis  may  manifest  itself  in  catarrhal  in- 
flammation, or  mucous  patches,  but  the  most  common  expres- 
sion is  a  gummatous  infiltration,  which  breaks  down,  ulcerates 
the  cartilages,  and  ultimately  leads  to  cicatrization  and  de- 
formity. 

Symptoms. — Hoarseness  of  the  voice,  hacking  cough,  and 
some  difficulty  in  deglutition.  Subjective  symptoms  are  often 
absent,  though  examination  may  reveal  extensive  lesions. 

Laryngoscopic  Examination. — Deep  ulcers  with  raised  edges, 
often  symmetrically  arranged.  Necrosis  of  the  cartilages  re- 
sults in  advanced  cases. 

Diagnosis. — The  history,  the  presence  of  other  syphilitic 
lesions,  tlie  deep  symmetrical  ulcers,  the  effect  of  treatment, 
and  the  absence  of  marked  pain  and  of  pulmonary  lesions  will 
serve  to  distinguish  it  from  tuberculous  laryngitis. 

Treatment. — The  system  should  be  rapidly  brought  under 
the  influence  of  antisyphilitic  remedies  ;  for  this  purpose  mer- 


176  DISEASES   OF   THE   EESPIEATORY    SYSTEM. 

curial  inuuctions  may  be  employed,  and  iodides  aud  mercurials 
given  internally  : — 

]^   Hydrarg.  chlor.  corros.,  gr.  j  ; 
Potass,  ioclidi,  3ij-oiv  ; 
Syr.  sarsaparillfe  comp.,  f^jss  ; 
Aquse,  q.  s.  ad  f^iij.— M. 
Sig. — A  teaspoonful  twice  daily  after  meals. 

Local  applications,  carefully  applied  by  the  aid  of  the  laryn- 
goscopic  mirror,  are  also  required.  Iodoform,  or  acid  nitrate 
of  mercury  (1  to  5  of  water),  may  be  selected  for  this  purpose. 

When'  the  laryngeal  movements  interfere  with  healing, 
tracheotomy  should  be  performed.  The  same  operation  or 
mechanical  dilatation  is  sometimes  required  for  the  resulting 
cicatricial  stenosis. 

SPASMODIC  CROUP. 

(False  Croup.) 

Definition. — Spasm  of  the  vocal  cords,  excited  by  catarrh 
of  the  larynx. 

Etiology. — The  attacks  usually  occur  in  young  children, 
and  are  iuduced  by  the  causes  of  catarrhal  laryngitis. 

Symptoms. — Generally  there  has  been  a  little  hoarseness 
and  cough  during  the  day,  and  at  night  the  child  is  awakened 
from  sleep  by  a  severe  paroxysm  of  suffocative  cough.  The 
latter  has  a  peculiar,  hard,  metallic  quality,  and  is  associated 
with  the  evidences  of  dyspnoea,  namely  :  Anxious  face,  dilating 
nostrils,  prominent  sterno-cleido-mastoids,  and  retraction  of 
the  base  of  the  chest  with  each  inspiratory  effort.  During  the 
paroxysm  the  skin  is  hot  and  the  pulse  is  tense  and  rapid.  In 
from  a  few  moments  to  an  hour  the  cough  ceases,  free  perspi- 
ration follows,  and  the  child  falls  to  sleep. 

Two  or  three  similar  attacks  may  occur  in  the  same  night, 
but  on  the  following  day  the  child  appears  quite  well.  A 
recurrence  of  the  seizures  for  several  successive  nights  is  not 
\.  infreqiient. 

Diagnosis.  Laryngismus  Stridulus. — This  is  a  pure  neu- 
rosis, and  is  often  associated  with  the  rachitic  diathesis.  The 
paroxysms  resemble  those  of  false  croup,  but  are  associated 


MEMBRANOUS   CROUP.  177 

with  a  peculiar  crowing  inspiration,  and  lack  catarrhal  symp- 
toms, such  as  hoarseness  and  cough. 

Progjsosis. — Always  favorable. 

Treatment. — A  sponge  moistened  with  hot  water  may  be 
applied  to  the  throat,  or  the  child  may  be  placed  in  a  hot  bath. 
If  these  simple  measures  fail,  an  emetic  will  almost  invariably 
bring  relief.  Wine  of  ipecac  (3j)  or  turpeth  mineral  (gr.  iij-v) 
may  be  selected.  Subsequent  treatment  should  be  directed  to 
the  laryngeal  catarrh. 

MEMBRAJN^OUS  CROUP. 

(Croupous  Laryngitis,  True  Croup,  Pseudo -membranous 
Laryngitis.) 

Definition. — A  non-infectious  inflammatory  disease  of  the  ^ 
larynx,  characterized  anatomically  by  the  formation  of  false 
membrane,  and  clinically  by  hoarseness,  barking  cough,  and 
dyspnoea  of  gradual  development. 

Etiology. — The  formation  of  false  membrane  in  the  larynx 
usually  results  from  diphtheria ;  but  a  membranous  inflamma- 
tion, non-infectious,  is  sometimes  observed.  Early  childhood 
(between  two  and  five  years)  and  exposure  to  cold  and  wet 
are  the  predisposing  causes. 

A  membranous  laryngitis  may  also  result  from  the  direct 
action  of  strong  acids  or  alkalies,  scalding  water,  or  steam. 

Pathology. — The  larynx  is  lined  with  a  grayish-white 
jjseudo-membrane  which  is  more  or  less  adherent.  The  fauces 
are  rarely  involved,  but  the  membrane  occasionally  extends  to 
the  trachea.  The  escape  of  the  fauces  is  a  point  of  difference 
between  membranous  croup  and  diphtheria,  for  in  the  latter 
the  fauces  are  usually  primarily  involved.  The  membrane  is 
quite  superficial,  and  rarely  involves  the  submucous  tissue. 

Under  the  microscope  a  fibrillar  network  is  found,  in  the 
meshes  of  which  are  leucocytes  and  epithelial  cells. 

Symptoms. — The  disease  usually  begins  with  the  symptoms 
of  catarrhal  laryngitis,  namely,  hoarseness,  barking  cough,  and 
slight  fever.  Soon  paroxysms  of  spasmodic  croup  appear,  and 
in  the  intervals  dyspnoea  gradually  develops.  The  respira- 
tions are  rapid  and  noisy,  and  are  often  associated  with  a 
12 


178  DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

whistling,  stridulous  inspiration.  There  is  moderate  fever. 
With  the  increasing  dyspnoea,  the  child  grows  extremely  rest- 
less ;  the  head  is  forcibly  extended ;  the  alse  of  the  nose  play ; 
the  sterno-cleido-mastoids  stand  out  prominently;  and  the 
base  of  the  chest  retracts  with  each  violent  inspiratory  effort. 
In  the  paroxysms  of  coughing,  a  piece  of  false  membrane  may 
be  detached  and  expectorated.  Hoarseness  soon  gives  place  to 
aphonia;  and  the  cough,  at  first  harsh,  gradually  becomes  in- 
audible. Finally,  the  lips  become  blue;  the  pulse  weakens ; 
the  temperature  falls ;  and  the  respirations  become  inaudible. 
Death  is  often  preceded  by  stupor  and  convulsions. 

Diagnosis.  SpasmodiG  Croup. — The  dyspnoea  is  parox- 
ysmal ;  the  attacks  usually  appear  at  night,  and  often  in  the 
midst  of  apparent  health ;  and  no  false  membrane  is  expecto- 
rated. In  true  croup  the  dyspnoea  develops  gradually  and 
becomes  extreme,  and  false  membrane  may  be  expectorated. 

Laryngeal  Diphtheria. — The  detection  of  false  membrane  in 
the  fauces,  a  history  of  contagion,  grave  systemic  symptoms, 
albuminuria,  and  such  complications  as  paralysis,  endocarditis, 
and  nephritis  would  indicate  diphtheria. 

Laryngismus  Stridulus. — This  is  a  nervous  affection,  charac- 
terized by  paj-oxysms  of  dyspnoea  accompanied  by  a  peculiar 
crowing  inspiration.  The  attacks  occur  periodically  in  the 
midst  of  apparent  health,  and  lack  fever  and  catarrhal  symp- 
toms. 

Prognosis. — Unfavorable ;  from  sixty  to  eighty  per  cent, 
perish  within  a  week  or  ten  days.  The  more  local  the  dis- 
ease, the  older  the  patient,  and  the  more  vigorous  he  is,  the 
better  the  prognosis.  A  return  of  voice  and  audible  breath- 
ing, a  loose  cough,  and  purulent  expectoration  are  favorable 
indications ;  but  increasing  rapidity  and  weakness  of  the 
pulse,  cyanosis,  and  debility  indicate  a  fatal  issue. 

Treatment.— The  temperature  of  the  room  should  be  kept 
at  70°,  and  the  atmosphere  should  be  moistened  by  the  gene- 
ration of  steam.  A  steam  atomizer  may  be  employed,  or  lime 
may  be  slacked  in  the  room.  Medicated  sprays  are  sometimes 
recommended ;  some  turpentine  or  oil  of  eucalyptus  may  be 
added  to  the  water  in  the  receiver  of  the  atomizer,  or  may  be 
placed  on  the  surface  of  water  which  is  kept  boiling  over  a 


LARYNGISMUS   STRIDULUS.  179 

^ove  or  spirit-lamp.     Hot  fomentations  or  an  ice-bladder  may 
be  applied  to  the  neck. 

The  best  internal  solvent  at  our  command  is  mercury.  A 
fiftieth  of  a  grain  of  the  bichloride  may  be  given,  well  diluted, 
every  hour  or  two  to  a  child  a  year  old,  or  a  quarter  of  a  grain 
of  calomel  may  be  given  every  hour  to  a  child  of  the  same  age, 
and  if  it  excites  diarrhoea,  a  little  paregoric  may  be  administered 
with  each  dose. 

^   Hydrarg.  chlor.  corros. ,  gr.  | ; 
Amnion,  chlor.,  gr.  xij  ; 
Aqure,  f^iij. — M. 
Sig. — A  teaspoonful  diluted  with  a  dessertspoonful  of  water  every 
hour  to  a  child  a  year  old. 

Quinine  (gr.  iij  iu  suppository)  may  be  employed  three  or 
four  times  daily. 

Stimulants  are  frequently  indicated.  An  emetic  may  assist 
in  the  expidsion  of  loose  membrane.  Turpeth  mineral  (gr. 
iij— v),  alum,  or  ipecac  may  be  selected. 

Topical  Medication. — In  the  very  young  it  may  be  impos- 
sible to  bring  medicated  sprays  iu  contact  with  the  affected 
parts,  but  when  it  is  feasible  much  benefit  accrues  from  this 
method  of  treatment.  Among  the  solutions  recommended 
may  be  mentioned,  lime-water,  Dobell's  solution,  lactic  acid 
(1  to  10  or  20),  and  peroxide  of  hydrogen  ;  a  fifty  per  cent, 
solution  of  the  last  is  often  very  efficient. 

When  these  remedies  fail,  and  the  dyspnoea  and  cyanosis  in- 
crease, and  the  pulse  grows  rapid  and  irregular,  intubation  or 
tracheotomy  must  be  performed.  The  results  of  intubation 
are  somewhat  more  encouraging  than  those  of  tracheotomy. 
Between  thirty  and  forty  per  cent,  recover  after  these  opera- 
tions. 

LARYNGISMUS  STRIDULUS. 

(Spasm  of  the  Glottis,  "Child-crowing.") 

Definition.  —  A  paroxysmal  neurosis,  characterized  by" 
spasm  of  the  adductors  of  the  larynx,  and  not  excited  by  any 
local  inflammation. 


180  DISEASES   OF  THE  EESPIBATOEY  SYSTEM. 

Etiology. — Early  life  (within  the  first  two  years),  male 
sex,  and  the  rachitic  diathesis  are  the  predisposing  causes. 
The  discharge  of  motor  force  apparently  arises  in  the  medulla 
(bulbar  epilepsy),  and  may  be  excited  by  reflex  irritation,  as 
in  teething  and  gastro-intestiual  disorders.  Some  regard  it  as 
\^a  symptom  of  tetany. 

Sympto^ls. — The  attacks  often  occur  on  waking  from  sleep, 
and  are  characterized  by  a  sudden  arrest  of  breathing  and 
tonic  muscular  spasms.  The  face  is  pale,  and  later  cyanosed ; 
the  eyes  are  rolled  up ;  the  body  is  arched  ;  the  thumbs  are 
turned  into  the  palms ;  the  legs  are  extended,  and  the  soles 
turned  inward.  In  a  few  seconds  the  spasm  relaxes,  and  air 
is  di'awn  through  the  glottis  with  a  shrill,  crowing  sound. 

The  seizures  vary  greatly  in  frequency ;  several  may  occur 
in  a  day,  or  they  may  be  weeks  apart. 

Diagnosis. — The  intermittent  character  of  the  affection  ; 
the  peculiar  crowing  inspiration  ;  the  absence  of  fever,  cough, 
and  hoarseness  will  serve  to  distinguish  laryngismus  from  o^oup. 

Prognosis. — Favorable.  In  the  very  young  death  may 
result  from  suffocation. 

Teeatmext.  The  Paroxysm. — Cold  water  may  be  dashed 
on  the  face  and  head,  or  a  few  drops  of  nitrite  of  amyl  or 
chloroform  may  be  placed  on  a  handkerchief  and  held  before 
the  nose. 

The  Interval.  —  Careful  search  should  be  made  for  some 
exciting  cause ;  the  gums  may  require  lancing,  or  the  gastro- 
intestiual  tract  may  demand  attention.  The  child  should  be 
placed  under  the  best  hygienic  conditions.  The  food  should 
be  plain  and  nutritious ;  tonics,  like  cod-liver  oil,  malt,  hypo- 
phosphites,  and  arsenic,  are  generally  indicated.  The  bromide 
of  potassium  is  an  efficient  antispasmodic,  and  may  be  advan- 
tageously combined  with  antipyrin  : — 

'^   Antipyrin,  gr.  xxiv-xlviij  ; 
Potass,  bromid.,  Siss-^ij  ; 
Syr.  auraut.  cort.,    f|ij  ; 
Aquee,  q.s.  ad  f^iij. — M. 
Sig. — A  teaspoonful  tlirice  daily. 


(EDEMA  OP  THE  LARYNX.  181 

(EDEMA  OF  THE  LARYNX. 

(Qjdema  of  the  Glottis.) 

DEPiisriTioisr. — An  infiltration  of  serous  fluid  into  the  sub- 
mucous tissue  of  the  larynx. 

Etiology, — It  occasionally  results  from  severe  attacks  of 
catarrhal  laryngitis.  It  may  be  induced  by  severe  inflamma- 
tion of  neighboring  organs — as  the  tonsils,  parotid  glands, 
and  pharynx.  It  may  be  a  complication  of  some  acute  infec- 
tious disease — like  diphtheria,  scarlet  fever,  or  facial  erysipelas. 
It  is  sometimes  associated  with  ulcerative  aflections  of  the 
larynx,  like  tuberculosis  and  syphilis.  It  may  be  excited  by 
the  irritation  of  burns,  scalds,  or  caustics.  It  occasionally 
occurs  abruptly  in  the  course  of  Bright's  disease. 

Pathology. — The  connective  tissue  of  the  larynx  is  infil- 
trated with  a  serous  or  sero-purulent  fluid.  The  mucous  mem- 
brane is  tense  and  changed  in  color. 

Symptoms. — Hoarseness  of  the  voice,  and  later  aphonia ; 
extreme  dyspnoea,  at  first  on  inspiration  but  later  on  expiration 
also ;  stridulous  respiration ;  barking  cough ;  and  the  evi- 
dences of  dyspnoea,  namely :  Anxious  face,  protruding  eyes, 
blue  lips,  prominent  sterno-cleido-mastoids,  and  retraction  of 
the  base  of  the  chest.  When  the  epiglottis  is  involved  the 
swelling  can  be  detected  by  the  finger  on  the  throat. 

Laryngoscopic  Examination.  —  The  mucous  membrane  is 
swollen  and  of  a  reddish-purple  color.  The  epiglottis  may 
resemble  a  round  translucent  tumor.  In  infraglottic  oedema 
the  upper  part  of  the  larynx  may  appear  normal,  but  swollen 
and  oedematous  membrane  is  seen  projecting  through  the 
glottis.     The  vocal  cords  are  rarely  affected. 

Prognosis. — Extremely  grave. 

Treatment, — When  the  symptoms  are  not  urgent,  leeches 
or  blisters  may  be  applied  over  the  larynx,  and  astringent  solu- 
tions (tannic  acid  or  alum)  sprayed  on  the  oedematous  tissues. 
When  the  symptoms  persist,  the  parts  should  be  scarified,  and 
if  this  fails  to  relieve  the  dyspnoea,  tracheotomy  should  be 
performed. 


182  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

BRONCHITIS. 

Definition. — An  inflammation  of  the  bronchial  tnbes, 
characterized  by  substernal  soreness,  cough,  muco-purulent 
expectoration,  and  dry  and  moist  rales. 

Varieties.: — (1)  Acute  catarrhal  bronchitis.  (2)  Chronic 
bronchitis.  (3)  Capillary  bronchitis.  (4)  Fibrinous  bron- 
chitis. 

Acute  Catarrhal  Bronchitis 

Etiology. — A  cold,  damp  climate  ;  changeable  weather ; 
occupations  which  necessitale  confinement,  or  the  inhalation  of 
irritating  dusts  or  vapors  ;  debility  ;  the  gouty  diathesis ;  and 
chronic  heart  disease  are  general  predisposing  factors. 

Exposure  to  cold  and  wet,  particularly  when  the  body  is 
overheated,  or  the  inhalation  of  irritating  gases  or  dusts  is  the 
usual  exciting  cause.  Acute  bronchitis  is  also  an  associated 
condition  in  certain  infectious  diseases,  especially  measles, 
whooping-cough,  typhoid  fever,  and  influenza. 

Pathology. — In  most  cases  the  trachea  and  large  tubes 
only  are  affected.  The  mucous  membrane  is  red,  swollen,  in- 
jected, and  more  or  less  covered  with  tenacious  muco-pus. 

Microscopic  examination  reveals  desquamation  of  epithe- 
lium and  infiltration  of  the  submucous  tissues  with  leucocytes. 

Symptoms. — Chilliness;  malaise;  a  sense  of  soreness  and 
constriction  behind  the  sternum,  which  is  increased  by  cough- 
ing ;  slight  fever  (100°-102°)  with  its  associated  symptoms ; 
cough  at  first  dry  and  painful,  but  later  accompanied  by 
muco-purulent  expectoration  which  becomes  quite  free  as  the 
inflammation  subsides. 

Physical  Signs. — Inspection,  palpation,  and  percussion 
usually  give  negative  results. 

Auscultation  at  first  reveals  sibilant  and  sonorous  rales  on 
both  sides  of  the  chest,  and  in  the  second  stage,  when  secretion 
is  established,  moist  rales. 

Diagnosis.  Influenza — High  fever,  intense  pain  in  the 
head,  back,  and  limbs,  and  great  prostration  will  serve  to  dis- 
tinguish influenza  from  bronchitis  when  the  former  is  prevalent. 


BRONCHITIS.  183 

Catarrhal  Pneumonia. — Moderately  high  and  irregular  fever, 
prostration,  rapid  breathing,  dyspncea,  and  physical  signs  indi- 
cating consolidation  will  serve  in  the  recognition  of  pneumonia. 

Prognosis. — Favorable.  In  the  old,  young,  and  feeble 
there  is  danger  of  its  leading  to  capillary  bronchitis  or  catar- 
rhal pneumonia. 

Treatment. — The  abortive  treatment  consists  in  the  use 
of  hot  foot-baths,  a  mustard  plaster  to  the  chest,  the  internal 
administration  of  hot  drinks,  and  a  full  dose  of  Dover's  pow- 
der (gr.  x)  with  which  quinine  may  be  advantageously  com- 
bined. This  method  is  ouly  applicable  in  the  initial  stage,  and 
to  those  patients  who  are  willing  to  remain  indoors  for  the  fol- 
lowing twenty-four  hours. 

The  young,  old,  and  enfeebled  should  be  confined  to  bed. 
A  turpentine  stupe,  mustard  plaster,  or  iodine  may  be  applied 
to  the  chest. 

In  the  early  stage  when  there  is  substernal  pain  with  little 
or  no  expectoration,  sedative  expectorants,  like  ipecacs,  the  veg- 
etable salts  of  potassium,  antimony,  and  apomorphine  are  indi- 
cated ;  and  it  is  Avell  to  combine  with  them  an  opiate  to  check 
the  harassing  cough. 

^i   Potass,  citrat.,  3ss  ; 

Apomorphina?  hydrochlor.,  gr.  j ; 
Syr.  ipecac,  f  ^ss  ; 
Succi  limonis,  fgij  ; 

Syr.  simp.,  q.  s.  ad  f5iv.— M.     (Wood.) 
Sig. — A  dessertspoonful,  in  water,  every  three  hours. 

Or— 

^   Yini  ipecacuanhce,  f  .^ij  ; 

Liq.  potass,  citrat.,  f^iv  ; 

Tinct.  opii  camph., 

Syr.  acacite,  aa  f5j. — M.     (DaCosta.) 
Sig. — Tablespoonful  thrice  daily. 

In  severe  cases  with  dyspncea,  inhalations  from  a  steam 
atomizer  often  give  relief.  Wine  of  ipecac  (with  twice  its 
volume  of  water),  tincture  of  lobelia,  or  tincture  of  conium 
may  be  employed  for  this  purpose. 

In  the  later  stages,  when  expectoration  has  been  established, 
stimulating  expectorants  are  useful,  such  as  ammonium  chlo- 
ride, squills,  terpiu  hydrate,  terebene,  tar,  or  eucalyptus. 


184  DISEASES   OF   THE   RESPIRATOEY  SYSTEM. 

R   Morphinse  sulphatis, 

Potassii  C)'anidi,  aa  gr.  iss ; 

Terpini  hydratis,  gr.  xl ; 

Olei  eucalypti,  f3j- 
Pone  in  capsulas  No.  xx. 
Sig. — One  every  two  hours. 

Or— 

^   Tinct.  opii  cam  ph.,  f^ij  ; 
Syr.  prun.  virgin.,  fgiss  ; 
Syr,  picis  liquid^e,  q.  s.  ad  f  ^iv. — M. 
Sig. — A  tablespoonful  thrice  daily. 

Or— 

]^   Terebeni,  f|ss. 
Sig.  — Five  drops  on  sugar,  gradually  increased  to  ten  thrice  daily. 

Chronic  Bronchitis. 

(Chronic  Bronchial  Catarrh,  Winter  Cough.) 

Etiology. — It  may  result  from  the  continuation  of  an 
acute  attack ;  but  it  most  commonly  develops  gradually  from 
the  causes  which  induce  the  acute  disease,  namely,  a  cold,  damp 
climate,  changeable  weather,  gouty  diathesis,  chronic  nephritis, 
and  heart  disease.     It  is  especially  common  in  the  old. 

It  is  an  associated  condition  in  emphysema,  phthisis,  chronic 
interstitial  pneumonia,  and  in  many  cases  of  asthma. 

Pathology. — The  mucous  membrane  of  the  bronchi  is 
sometimes  thickened  and  roughened  from  an  overgrowth  of 
the  connective  tissue ;  in  other  cases  the  mucosa  is  thin  from 
atrophic  changes.  The  surface  is  usually  covered  with  muco- 
pus  ;  ulcers  are  occasionally  noted. 

Long-standing  bronchitis  leads  to  dilatation  of  the  tubes 
(Bronchiectasis)  and  to  emphysema. 

Symptoms. — Persistent  cough,  and  more  or  less  muco-puru- 
lent  expectoration ;  a  sense  of  soreness  behind  the  sternum. 
Fever  is  usually  absent,  and  unless  the  disease  is  very  severe, 
the  general  health  may  be  fairly  well  preserved.  Dyspnoea 
on  exertion  is  a  troublesome  symptom  ;  it  however  belongs  more 
to  the  resulting  emphysema  than  to  the  bronchitis. 

Physical  Signs. — Unless  emphysema  has  developed,  in- 
spection, palpation,  and  percussion  give  negative  results. 


BRONCHITIS.  185 

Auscultation  reveals  rales,  some  of  which  are  dry  and 
wheezing,  while  others  are  moist  and  bubbling. 

Special  Varieties. — (1)  Rheumatic  bronchitis.  (2)  Bron- 
chorrhcea.     (3)  Dry  catarrh. 

Rheumatic  Bronchitis. — This  form  occurs  in  those  of  a  rheu- 
matic diathesis,  and  is  characterized  by  severe  paroxysmal 
cough,  the  expectoration  of  scanty  tenacious  mucus,  and  by 
aching  pains  in  various  parts  of  the  chest.  It  is  especially  in- 
fluenced by  atmospheric  changes,  and  does  not  yield  to  the 
ordinary  treatment  of  bronchitis. 

Bronchorrhcea. — This  term  is  applied  to  cases  of  chronic 
bronchitis  which  are  associated  with  a  very  copious  expectora- 
tion. The  sputum  is  generally  muco-purulent,  and  sometimes 
very  oifensive  (Fetid  })ronchitis). 

JDry  Catarrh. — This  form,  described  by  Laennec  as  catarrhe 
sec,  is  characterized  by  severe  spells  of  coughing  which  are 
accompanied  by  little  or  no  expectoration.  It  is  generally 
seen  in  the  old  in  association  with  emphysema  or  asthma. 

Diagnosis.  Phthisis. — The  absence  of  fever,  of  hemorrhage, 
of  bacilli  in  the  sputa,  and  of  signs  indicating  consolidation 
will  serve  to  distinguish  chronic  bronchitis  from  phthisis. 

Bronchiectasis. — This  often  results  from  chronic  bronchitis. 
Very  profuse  fetid  sputa,  expelled  periodically  in  gushes,  and 
perhaps  physical  signs  of  cavity  over  the  main  bronchi,  poste- 
riorly, indicate  bronchiectasis. 

Emphysema. — Much  dyspnoea,  distention  of  the  chest,  hyper- 
resonance  on  percussion,  and  a  prolonged  feeble  expiration  on 
auscultation  indicate  emphysema. 

Sequels. — Emphysema,  bronchiectasis,  and  dilatation  of 
the  right  ventricle 

Prognosis. — Perfect  recovery  is  rarely  attainable,  but  the 
disease  is  not  incompatible  with  long  life. 

Treatment, — A  careful  regulation  of  the  hygiene ;  this 
includes  attention  to  diet,  clothing,  bathing,  exercise,  etc. 
Bronchitis  dependent  on  heart  or  kidney  disease  will  require 
remedies  directed  to  those  organs.  The  general  vitality  is 
frequently  reduced,  and  tonics  like  cod-liver  oil,  hypophos- 
phites,  iron,  quinine,  and  strychnine  are  often  valuable  adjuncts 
to  the  special  treatment.     A  change  of  climate  often  secures 


186  DifJEASES  OE  THE  RESPIRATORY  SYSTEM. 

permanent  relief.  In  this  country  the  extreme  south-western 
territory,  inchiding  New  Mexico,  Arizona,  and  Southern  Cali- 
fornia, possesses  many  atmospheric  advantages. 

Alteratives  like  iodide  of  potassium  (gr.  v-x  thrice  daily)  are 
often  serviceable  in  chronic  bronchitis  with  little  expectoration. 

Counter-irritants — blisters,  tincture  of  iodine,  or  croton  oil — 
prove  useful. 

Stimulating  expectorants — chloride  of  ammonium,  terebene, 
tar,  eucalyptus,  oil  of  sandalwood,  and  copaiba — are  generally 
indicated  : — 

R    Strychniiife  sulphatis,  gr.  ss ; 

Codeinse,  gr.  vj  ; 

Terebeni, 

Olei  santali,  aa  f^ss. 
Pone  in  capsulas  No.  xii. 
Sig. — One  every  three  hours. 

Or— 

^   Copaibpe,  giij ; 

Acacife  et  sacchar.  alb.,  aa  q.  s.  ; 
Spt.  lavandulte  comp.,  f^ss  ; 
Aqujfi,  q.s.  ad  f^vj. — M. 
Sig.— Atablespoonful  thrice  daily. 

Or— 

l^:.  Apomorphinse  hydroclilor. ,  gr.  i  ; 
Syr.  prun.  virg.,  fgij ; 

Syr.  picis  liquidte,  fgiv.— M.     (Murrell.) 
Sig. — A  tablespoonful  thrice  daily. 

The  method  of  treating  chronic  bronchitis  by  inhalations, 
which  has  been  so  ably  advocated  by  Dr.  Murrell  of  London, 
is  extremely  useful,  especially  in  patients  with  weak  stomachs, 
in  whom  syrups  should  be  avoided. 

Wine  of  ipecac  (with  twice  its  volume  of  w^ater),  terebene 
(with  equal  parts  of  benzoinol  or  liquid  vaseline),  creasote,  or 
carbolic  acid  may  be  so  employed. 

^.   Acid,  carbol.,  gr.  xxx  ; 

Tinct.  opii  camph.,  f^iij.— M.    {N.  S.  Davis.) 
Sig. — A  fluid  drachm  with  half  a  pint  of  hot  water  in  the  inhaler, 
thrice  daily. 

An  inexpensive  inhaling  apparatus  is  made  by  Codmau  & 
Shurtleif,  of  Boston. 


BRONCHITIS.  187 

Cai)illary  Bronchitis. 

(Suffocative  Catarrh.) 

Definition.  —  An  inflammation  of  the  smaller  bronchi, 
generally  secondary  to  simple  bronchitis. 

Etiology. — Simple  bronchitis  is  apt  to  involve  the  capil- 
lary tubes  in  the  young,  old,  and  debilitated.  It  is  often  a 
complication  of  certain  infections  fevers — like  measles,  whoop- 
ing-cough, diphtheria,  and  influenza. 

Pathology. — The  mucous  membrane  of  the  finer  tubes  is 
red,  swollen,  and  injected,  and  the  tubes  are  filled  with  tena- 
cious mucus.  In  most  cases  more  or  less  catarrhal  pneumonia 
results  from  the  extension  of  the  inflammation  into  the 
air-vesicles.  Areas  of  collapse  from  occlusion  of  the  bronchi 
are  often  observed. 

Symptoms. — Severe  spells  of  coughing,  which  in  children 
are  unaccompanied  with  expectoration  ;  rapid  respirations  (60 
to  80  per  minute);  dyspnoea;  high  fever  (104°-105°);  and  a 
weak,  rapid  pulse.  Later  the  lips  become  blue,  the  extremities 
cold,  and  the  mind  dull,  and  death  frequently  results  in  a  few 
days  from  exhaustion  and  asphyxia. 

Physical  Signs. — Inspection  reveals  evidences  of  dyspnoea  : 
Playing  of  the  aire  of  the  nose,  blue  lips,  anxious  face,  promi- 
nent sterno-cleido-mastoids,  and  retraction  of  the  base  of  the 
chest  from  obstruction  to  the  entrance  of  air. 

Percussion. — The  resonance  may  be  normal,  but  large 
areas  of  collapse  or  pneumonic  consolidation  will  yield  dulness." 

Auscultation. — -Weak  breathing,  and  whistling  sibilant  rales 
or  fine,  crackling,  moist  rales. 

Diagnosis.  Catarrhal  Pneumonia. — This  is  a  natural  out- 
come of  capillary  bronchitis  and  usually  complicates  it.  The 
detection  of  areas  of  consolidation  in  catarrhal  pneumonia  is 
the  only  diagnostic  difference. 

(Edema  of  the  Lungs. — The  history  of  some  chronic  causal 
disease  and  the  absence  of  fever  will  assist  in  the  diagnosis  of 
oedema. 

Prognosis. — In  young  children  it  is  very  grave.  In  older 
and  more  vigorous  patients  the  prognosis  is  much  more 
favorable. 


188  DISEASES  OF   THE  EESPIRATORY  SYSTEM. 

Treatment. — Absolute  rest.  The  temperature  of  the  room 
should  be  kept  uniformly  at  70°  or  75°.  The  atmosphere 
should  be  rendered  moist  by  the  generation  of  steam.  A  tur- 
pentine stupe  may  be  applied  to  the  chest,  which  should  be 
protected  by  a  cotton  jacket.  The  diet  ought  to  be  liquid  or 
semi-liquid  and  nutritious.  Stimulants  are  frequently  indi- 
cated. Quinine  may  be  given  in  suppository  as  a  support  to 
the  system.  Carbonate  of  ammonium  is  an  invaluable  cardiac 
and  respiratory  stimulant  in  these  cases  : — 

'^  Ammon.  carb.,  gr.  xv  ; 

Pulv.  acacise  et  sacchar.,  aa  q.  s.  ; 
Spt.  lavandulfe  comp.,  fgij  ; 
Aquae,  q.  s.  ad  f.^ij. — M. 
Sig. — A  teaspoonful  every  two  hours  to  a  child  of  two  or  three 
years. 

When  the  dyspnoea  is  marked  an  emetic  is  useful  in  expel- 
ling mechanically  mucus  from  the  bronchi.  Wine  of  ipecac 
(3ss-3j  for  a  child)  may  be  selected. 

When  the  fever  is  high,  it  should  be  reduced  by  sponging 
with  cool  water,  or  by  the  cold  bath. 

Fibrinous  Bronchitis. 

(Croupous  Bronchitis,  Pseudo-membranous  Bronchitis.) 

Definition. — A  primary  inflammatory  disease  of  the  bronchi 
associated  with  the  formation  of  false  membrane. 

Etiology. — The  causes  are  unknown.  Male  sex,  early 
manhood,  and  chronic  pulmonary  disease,  like  phthisis,  emphy- 
sema, and  pleurisy,  appear  to  be  predisposing  factors. 

Pathology. — The  disease  is  often  limited  to  a  certain  num- 
ber of  bronchi.  Some  of  the  affected  tubes  are  found  filled 
with  a  fibrinous  exudate,  while  others  are  found  empty  and  ■ 
show  a  loss  of  epithelium.  The  casts  are  usually  ex|3elled  in 
the  form  of  whitish  balls,  and  when  unrolled  in  water  present 
branching  moulds  of  the  divisions  and  subdivisions  of  the 
affected  bronchi.  On  close  examination  they  are  found  to  be 
hollow  and  laminated.  Under  the  microscope,  a  homogeneous 
or  fibrillated  membrane  is  observed,  imbedded  in  which  are 


DILATATION   OF   THE   BEONCHIAL  TUBES.  189 

leucocytes,  fat-drops,  particles  of  pigment,  epithelial  cells,  and 
occasionally  Ley  den's  octahedral  crystals. 

Symptoms. — Acute  and  chronic  forms  are  recognized.  The 
former  is  rare,  and  manifests  the  symptoms  of  a  severe  attack 
of  acute  bronchitis,  but  the  sputa  contain  fibrinous  casts,  and 
there  is  marked  dyspnoea. 

The  chronic  form  is  characterized  by  severe  cough,  parox- 
ysms of  dyspnoea,  and  the  expectoration  of  fibrinous  plugs. 
The  physical  signs  are  those  of  chronic  bronchitis.  The  disease 
often  lasts  a  few  weeks,  and  then  disappears  to  return  again  at 
definite  periods. 

Prognosis. — In  the  acute  variety  the  prognosis  must  be 
guarded ;  death  frequently  results  from  suffocation. 

The  chronic  variety  runs  a  very  protracted  course. 

Treatment. — In  the  acute  disease,  the  atmosphere  of  the 
room  should  be  kept  moist  and  uniformly  warm.  Calomel 
(gr.  ^  every  two  hours)  may  be  administered  as  in  other  mem- 
branous inflammations,  and  may  be  followed  by  iodide  of 
potassium.  Inhalations  of  alkaline  vapors  (lime-water)  exert 
a  solvent  effect.  Counter-irritants  should  be  applied  to  the 
chest.     Emetics  sometimes  aid  in  the  expulsion  of  casts. 

In  the  chronic  form  iodide  of  potassium  may  be  given  in 
conjunction  with  stimulating  expectorants. 

DILATATION  OF  THE  BRONCHIAL  TUBES. 

(Bronchiectasis.) 

Definition. — A  universal  or  circumscribed  dilatation  of 
the  bronchi. 

Etiology. — Chronic  inflammation  of  the  tubes  and  the 
contraction  of  surrounding  pulmonary  tissue  are  the  prime 
causes ;  hence,  it  is  generally  secondary  to  chronic  bronchitis, 
phthisis — particularly  fibroid — chronic  interstitial  pneumonia, 
and  chronic  pleurisy  with  adhesions. 

Pathology. — The  dilatation  results  from  weakening  and 
atony  of  the  tubes,  and  from  their  subjection  to  strain  in 
coughing,  or  to  the  traction  of  shrinking  connective  tissue,  as 
in  fibroid  phthisis. 

Two  forms  are  noted :   (1)  The  cylindrical  form,  in  which 


190  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

the  tubes,  particularly  those  of  medium  size,  are  iiniformly 
dilated  iu  one  or  both  lungs ;  and  (2)  the  saccular  Ibrm,  in 
which  the  tubes  swell  out,  here  and  there,  into  circumscribed 
dilatations  which  may  reach  several  inches  in  diameter.  This 
form  is  especially  noted  in  fibroid  phthisis.  The  avails  of  the 
bronchiectatic  cavity  are  extremely  atrophied,  the  surface  is 
generally  smooth  and  shining,  but  ulcerations  are  not  un- 
common. 
/  Symptoms. — Cough,  dyspnoea,  and  copious  expectoration. 
The  last  is  characteristic;  it  is  apt  to  occur  periodically  iu 
gushes ;  the  material  has  a  highly  offensive  odor,  and  when 
allowed  to  stand  in  a  glass  vessel  separates  into  three  layers  : 
an  upper  layer  of  dirty  brown  froth,  a  middle  layer  of  turbid 
mucus,  and  an  under  layer  of  decomposed  pus.  Microscopi- 
cally it  contains  pus  corpuscles,  fat  crystals,  crystals  of  hiema- 
toidin,  and  numerous  microorganisms,  but  no  tubercle  bacilli. 
Elastic  fibres  are  rarely  found. 

Physical  Signs. — In  the  cylindrical  variety  the  signs  are 
those  of  chronic  bronchitis.  The  saccular  variety  may  present 
the  signs  of  tuberculous  cavities,  localized  tympany,  cavernous 
breathing,  gurgling  rdles,  and  pectoriloquy. 

Diagnosis.  - — The  differentiation  of  bronchiectasis  from 
'phthisis  is  difficult  and  often  impossible.  The  discovery  of 
tubercle  bacilli  always  indicates  phthisis.  Bronchiectatic  cavi- 
ties are  usually  located  in  the  lower  lobes,  and  rarely  in  the 
apices. 

Prognosis. — This  will  depend  on  the  primary  disease ; 
since  the  common  causes  are  lono-standino;  bronchitis  and 
fibroid  phthisis,  there  can  be  little  hope  of  cure.  Amelioration 
is  all  that  can  be  expected. 
^  Treatment. — Tonics  are  often  indicated.  Stimulant  and 
antiseptic  expectorants  like  turpentine,  terebene,  eucalyptus, 
oil  of  sandalwood,  and  tar  are  sometimes  useful. 

Inhalations  of  terebene,  carbolic  acid,  or  dilute  peroxide  of 
hydrogen  lessen  cough  and  destroy  the  fetid  odor  of  the  breath. 
Codeine  (gr.  \)  may  be  employed  to  allay  cough. 


ASTHMA.  191 

ASTHMA. 

Definition. — Paroxysmal  dyspnoea  due  to  spasm  of  the 
tubes  or  to  swelling  of  their  mucous  membrane. 

Etiology. — Asthma  is  a  symptom  of  several  diseases,  but 
a  hypersensitive  condition  of  the  mucous  membrane  of  the  re- 
spiratory tract  appears  to  be  essential  to  its  production.  When 
this  condition  prevails,  asthma  may  be  induced  (1)  by  the  pul- 
monary congestion  of  cardiac  disease  (Cardiac  asthma) ;  (2) 
by  the  ursemic  intoxication  or  transient  pulmonary  oedema  of 
Bright's  disease  (Renal  asthma) ;  or  (3)  by  some  irritant  from 
without,  as  the  pollen  of  plants  (Hay  asthma).  (4)  Sometimes 
the  paroxysms  are  excited  by  the  most  trivial  causes,  as  an 
atmospheric  change  or  a  peculiar  odor,  and  to  this  form  many 
writers  restrict  the  term  asthma.  This  last  will  be  discussed 
under  the  head  of  essential  asthma. 

Essential  Asthma. 

(Bronchial  Asthma,  Nervous  Asthma,  Spasmodic  Asthma.) 

Etiology. — Nervous  temperament,  an  hereditary  tendency, 
early  life,  disease  of  the  naso-pharynx,  and  the  gouty  diathesis, 
are  predisposing  factors. 

Barometric  and  thermometric  changes ;  the  inhalation  of 
dust ;  the  odor  of  certain  plants,  animals,  or  fruits ;  excite- 
ment ;  reflex  irritation,  particularly  a  loaded  stomach ;  a 
change  of  locality  ;  and  bronchial  catarrh,  are  exciting  causes. 

Pathology. — The  disease  is  a  pure  neurosis,  and  the  par- 
oxysms probably  result  from  a  spasm  of  the  smaller  tubes,  or 
turgescence  of  their  mucous  membrane. 

Symptoms. — The  paroxysms  often  appear  suddenly,  but  in 
some  cases  certain  symptoms  precede  and  give  warning  of  the 
approaching  attack  ;  among  these  are  chilliness,  flatulence, 
sneezing,  and  a  copious  discharge  of  pale  urine.  The  patient 
is  often  seized  at  night.  There  is  a  sense  of  oppression  and 
anxiety  followed  by  dyspnoea  so  intense  that  he  runs  to  the 
window  for  air,  or  sits  upright  with  his  arms  in  such  a  position 
that  he  can  bring  into  play  theauxiliary  muscles  of  respiration. 
The  face  is  pale,  the  lips  blue,  the  eyes  prominent  and  con- 


192  DISEASES   OF  THE  RESPIEATOEY  SYSTEM. 

gested,  and  the  body  cold  and  covered  with  sweat.  The  re- 
spirations are  not  rapid,  but  labored  and  noisy.  Cough  is  often 
present  and  is  associated  with  the  expectoration  of  scanty 
viscid  mucus.  On  close  examination  little  grayish  balls  are 
noted  in  the  sputum,  and  when  unravelled,  they  are  found  to 
be  composed  of  delicate  spii'als  of  mucus,  which  have  been 
moulded  in  the  finer  bronchioles  (Curschmann's  spirals). 

Fig.  16 


Curschmann's  Si^irals.    a,  Central  fibre. 

Microscopic  examination  also  reveals  octahedral  crystals 
similar  to  those  found  in  leukaemia  (Charcot-Leyden  crystals). 

The  paroxysms  may  last  from  a  few  minutes  to  many  hours, 
and  may  recur  for  several  successive  nights,  or  may  disappear 
entirely  for  weeks  or  months. 

Physical  Signs. — Iinspection  reveals  evidences  of  dyspnoea 
and  distention  of  the  chest. 

Percussion  generally  yields  hyper-resonance. 

Auscultation. — A  prolonged,  high-pitched,  wheezing  expira- 
tion, with  abundant  sonorous  and  sibilant  rales.  The  expira- 
tory wheezing  may  be  audible  over  the  entire  room. 

Diagnosis. — Cardiac  and  renal  asthma  are  to  be  distin- 
guished from  essential  asthma  by  the  history,  and  by  the  evi- 
dence of  organic  heart  or  kidney  disease. 

Hay  asthma  is  recognized  by  the  associated  coryza  and  by 
its  periodic  occurrence  every  spring  or  fall. 


ASTHMA.  193 

Laryngeal  obstruction  from  foreign  bodies,  croup,  paralysis 
of  the  vocal  cords,  or  oedema. — The  dyspnoea  is  ^vitll  inspira- 
tion, and  the  chest  instead  of  being  distended  is  retracted, 
especially  at  the  base. 

Sequelae.  —  Emphysema  invariably  follows  when  the 
asthma  is  of  long  duration  ;  it  results  from  the  tension  to 
which  the  vesicles  are  subjected  during  the  expiratory  effort. 
Dilatation  of  the  right  ventricle  is  also  a  remote  sequel. 

Peognosis.  —  The  disease  does  not  prove  fatal  except 
through  complications  or  sequelae.  In  young  persons  without 
an  inherited  tendency  the  prognosis  should  be  guardedly 
favorable ;  it  frequently  subsides  at  puberty.  Cases  associated 
with  some  definite  reflex  cause,  as  nasal  obstruction,  often 
recover  when  the  latter  is  removed.  The  older  the  patient,  the 
greater  the  inherited  tendency,  the  more  unfavorable  becomes 
the  prognosis. 

Teeatment.  The  Attack. — Prompt  relief  often  follows 
the  inhalation  of  nitrite  of  amyl  (five  or  six  drops  in  a  glass 
or  on  the  handkerchief),  iodide  of  ethyl  (twenty  to  thirty 
drops),  or  a  few  whiffs  of  chloroform.  Smoking  cigarettes  of 
belladonna  and  stramonium  leaves  wrapped  in  nitre-paper — • 
paper  which  has  been  soaked  in  a  saturated  solution  of  salt- 
petre and  dried — will  often  suffice  in  mild  attacks.  Nitre- 
paper  may  be  burned  in  the  room  and  the  fumes  inhaled. 

The  application  of  dry  cups  or  thin  poultices  to  the  chest  is 
often  a  valuable  adjunct  to  the  treatment.  Morphine  (gr.  ^—1) 
with  sulphate  of  atropine  (gr.  yi-g-)  will  often  cut  short  an 
attack.  Internally,  sedatives  like  Hoffmann's  anodyne  (5ss), 
tincture  of  lobelia  (i^l  xx),  and  bromide  of  potassium  (gr.  xxx), 
are  sometimes  useful. 

R   Tinct.  belladonnae, 

Tinct.  lobelise,  aa  f^iiss ; 
Spiritus  aether,  comp., 
Tinct.  opii  camph.,  aa  f3vj ; 
Syrup,  prun.  Virgin  ianee,  q.  s.  ad  f^iv. — M. 
Sig. — A  dessertspoonful  every  three  hours. 

The  Intei'val. — Careful  search  should  be  made  for  some  re- 
flex irritation,  especially  in  connection  with  the  naso-pharynx. 
An  easily-assimilable  diet  must   be   selected ;    in   nocturnal 
13 


194  DISEASES  OF  THE   EESPIRATOEY  SYSTEM. 

asthma  the  evening  meal  should  be  very  light.  Graduated  ex- 
ercise and  frequent  bathing,  followed  by  friction  of  the  skin, 
will  add  to  the  general  vigor.  A  change  of  climate  is  de- 
sirable, but  there  is  no  fixed  rule  in  the  selection  of  locality. 
Many  asthmatics  do  well  in  the  city,  but  a  dry  atmosphere 
and  a  high  altitude  are  better  suited  to  the  majority.  Busey 
claims  excellent  results  from  the  habitual  wearing  of  an  oil- 
silk  jacket  in  asthma  associated  with  bronchitis.  Among  the 
remedies  arsenic  and  iodide  of  potassium  hold  a  high  place  as 
alteratives.  Fowler's  solution  (three  drops,  gradually  increased 
to  ten  or  more,  thrice  daily),  or  five  to  ten  grains  of  the 
iodide  may  be  administered  over  long  periods.  Nitroglycerin 
(gr.  j^o)?  ^^  nitrite  of  sodium  (gr.  iij-v  thrice  daily)  often  gives 
immunity  for  long  periods. 

HAY  ASTHMA. 

(Hay  Fever,  Autumnal  Catarrh,  Rose  Cold.) 

Definition. — A  catarrhal  affection  of  tlie  respiratory  tract, 
usually  occurring  periodically  every  spring  or  autumn,  excited 
by  the  action  of  some  atmospheric  irritant  upon  a  hyperses- 
thetic  mucous  membrane,  and  cLaracterized  by  coryza,  bron- 
chitis, and  asthmatic  seizures. 

Etiology. — An  inherited  tendency,  male  sex,  nervous  tem- 
perament, indoor  life,  and  chronic  nasal  catarrh  are  predis- 
posing factors.  The  attack  as  a  rule  occurs  in  the  autumn 
(Autumnal  catarrh),  or  in  the  spring  (Rose  cold),  and  is  excited 
by  certain  dusts,  vapors,  or  odors.  The  pollen  of  plants  seems 
to  be  a  common  excitant.  The  seizures  may  occur  at  any 
time  if  the  peculiar  irritant  is  present. 

Pathology. — An  essential  feature  is  the  hypersensitive 
condition  of  the  mucous  membrane,  and  this  is  often,  though 
not  invariably,  associated  with  hypertrophic  rhinitis. 

Symptoms. — Redness  of  the  conjunctivse  and  swelling  of 
the  eyelids ;  pruritus  of  the  pharynx,  nose,  and  eyes ;  sneez- 
ing; obstruction  of  the  nostrils;  watering  of  the  eyes;  a 
copious  discharge  of  mucus  from  the  nose ;  headache ;  cough  ; 
and  asthmatic  attacks  are  the  usual  phenomena. 

Bose  cold  usually  begins  in  May  or  June  and  runs  to  the 


PULMONARY  EMPHYSEMA.  195 

latter  part  of  July.     Autumnal  catarrh  begins  in  tlie  latter 
part  of  A  ugust  and  ends  with  the  first  frost. 

Peogjs'OSIs. — The  disease  runs  an  indefinite  course,  and 
rarely,  if  ever,  proves  fatal.  Cases  which  are  associated  with 
chronic  rhinitis  often  permanently  recover  on  the  removal  of 
the  latter.  In  other  cases,  the  prognosis  as  regards  immu- 
nity from  future  attacks  is  unfavorable. 

Treatment. — Careful  search  should  be  made  for  chronic 
nasal  disease,  and  if  found,  appropriate  treatment  instituted. 

A  change  of  climate  during  the  period  of  susceptibility 
exempts  most  patients.  A  sea-voyage  or  a  sojourn  in  some 
high-mountain  district,  like  the  White  Mountains,  Adiron- 
dacks,  Catskills,  or  Alleghanies  may  be  recommended. 

Tonics  are  usually  indicated,  and  quinine,  arsenic,  and 
strychnine  are  often  very  useful  when  administered  before  and 
during  an  attack.  To  allay  itching  and  lachrymation,  the 
eyes  may  be  washed  with  a  solution  of  boric  acid  (gr.  x  to  Jj), 
or  sulphate  of  zinc?  (gr.  i-ij  to  |j).  Sneezing,  nasal  fulness, 
and  discharge  are  often  relieved  by  medicated  sprays.  A  solu- 
tion of  cocaine,  or  the  following  may  be  employed ; — 

^  Menthol,  ^j-gij  ; 

01.  amygd.  dulc.  vel  beiizoinol,  f  gij-M. 
Sig. — Spray  into  the  nose  and  throat  every  few  hours. 

PULMONARY  EMPHYSEMA. 

Definition. — Abnormal  distention  of  the  lungs  with  air. 

Varieties. — (1)  Interlobular  emphysema :  This  form  is 
rare,  and  results  from  the  rupture  of  the  lung  and  escape  of 
air  into  the  interstitial  tissue.  (2)  Compensatory  emphysema  : 
When  a  lung  or  a  part  of  a  lung  is  disabled  from  any  cause, 
the  healthy  portions  distend  and  do  vicarious  work.  (3) 
Atrophic  or  senile  emphysema:  In  old  people  the  solids  of 
the  lung  atrophy,  so  that  a  relative  increase  of  air  results. 
(4)  Hypertrophic  emphysema.  The  last  three  varieties  are 
included  under  the  term  vesicular  emphysema. 


196  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

Hypertrophic  Emphysema. 

Definition. — A  pulmonary  disease  characterized  anatomi- 
cally by  dilatation  of  the  air-vesicles  and  atrojDhy  of  the  walls ; 
and  clinically  by  dyspnoea,  enlargement  of  the  thorax,  hyper- 
resonance,  and  weak  breathing. 

Etiology. — Congenital  weakness  of  the  lung  structure — 
probably  a  defective  development  of  elastic  tissue — is  an  im- 
portant predisposing  factor.  This  predisposition  may  be  trans- 
mitted through  several  generations. 

In  forced  expiration,  the  air  cannot  escape  with  sufficient 
rapidity  through  the  narrow  glottis,  and  the  backward  pres- 
sure stretches  the  air-vesicles ;  hence,  the  obstinate  cough  of 
chronic  bronchitis,  the  expiratory  straining  of  asthma,  and 
occupations  which  necessitate  forced  expiration,  like  playing 
ou  wind  instruments  and  glass-blowing,  are  causal  factors. 

Pathology. — The  lungs  are  enlarged,  and  do  not  collapse 
when  the  thorax  is  opened.  In  bad  cases  the  free  margins  are 
studded  with  large  bullae  or  blebs  which  have  resulted  from 
the  rupture  of  a  number  of  vesicles  into  a  common  sac.  The 
organs  are  pale,  and  have  a  soft  cotton-like  feel.  Microscopic 
examination  reveals  atrophy  of  the  vesicular  walls,  a  dimin- 
ished amount  of  elastic  tissue,  and  more  or  less  obliteration  of 
the  pulmonary  capillaries.  This  last  condition  leads  to  in- 
creased tension  in  the  pulmonary  artery  and  to  secondary 
hypertrophy  of  the  right  ventricle. 

Symptoms. — The  disease  generally  manifests  itself  in  middle 
life,  but  it  is  not  infrequently  observed  in  the  young.  Dys- 
pnoea, increased  by  exertion ;  cyanosis,  often  extreme  during 
attacks  of  acute  bronchitis  ;  and  cough,  from  the  associated 
bronchitis,  are  the  usual  symptoms.  In  advanced  cases  dropsy 
may  result  from  cardiac  failure. 

Physical  Signs. — The  neck  is  short,  and  the  sterno- 
cleido-mastoids  prominent.  The  thorax  is  likewise  short,  but 
broad  especially  in  its  antero-posterior  diameter.  This  con- 
figuration has  given  rise  to  the  term  "  barrel-shaped"  chest. 
On  respiration  there  is  little  expansion,  but  an  elevation  of 
the  thorax  as  a  whole.  The  apex-beat  is  invisible,  but  an 
abnormal  pulsation  is  often  noted  in  the  epigastrium. 


l>tJLMO]SrAIlY  EMPHYSEMA.  197 

Palpation. — Diminished  vocal  fremitus. 

Percussion.  —  Increased  resonance.  The  upper  level  of 
hepatic  dulness  is  depressed,  and  the  area  of  cardiac  dulness 
may  be  almost  obliterated. 

Auscultation. — Inspiration  is  short,  expiration  is  prolonged 
and  low-pitched,  or  inaudible.  Rales  resulting  from  the  asso- 
ciated bronchitis  are  frequently  heard.  The  pulmonary  second 
sound  is  accentuated. 

Complications. — Bronchitis,  asthma,  dilatation  of  the 
right  ventricle,  and  later,  tricuspid  regurgitation  and  dropsy. 

Diagnosis.  Chronic  Bronchitis. — The  dyspnoea,  thoracic 
enlargement,  hyper-resonance,  and  prolonged  expiration  sepa- 
rate emphysema  from  bronchitis. 

Pneumothorax. — This  is  almost  invariably  unilateral,  the 
resonance  is  tympanitic,  and  metallic  tinkling  and  bell- 
tympany  are  obtained  on  auscultation. 

Peognosis. — The  disease  is  generally  incurable ;  but  its 
advance  may  be  stayed  by  relieving  the  primary  condition. 
Emphysema  runs  a  long  course  and  is  in  itself  rarely  fatal, 
but  death  may  result  from  heart  failure  and  dropsy,  or  from 
intercurrent  pneumonia. 

Treatment. — The  remedies  advocated  in  chronic  bron- 
chitis and  asthma  are  often  applicable  here.  The  patient 
should  be  placed  under  the  most  favorable  hygienic  conditions. 
Iodide  of  potassium  (gr.  x  thrice  daily)  is  often  used  empiri- 
cally, and  sometimes  relieves  the  dyspnoea  and  cough.  Iron 
is  indicated  in  the  ansemic.  Strychnine  (gr.  4V^V)  ^^  ^  valu- 
able respiratory  and  cardiac  stimulant,  and  may  be  combined 
with  digitalis  when  there  are  symptoms  of  heart  failure. 

Si    ^   Strychnin,  sulph. ,  gr.  |^ ; 

Pulv.  digitalis, 

Pulv.  scillse, 

Ferri  redact,,  aa  gr.  xx. — M. 
Ft.  in  pil.  No.  xx. 
Sig. — One  thrice  daily. 

The  inhalation  of  oxygen,  or  the  inspiration  of  compressed 
air  followed  by  expiration  into  rarefied  air  is  sometimes  a  useful 
measure. 


198  DISEASES  OF  THE   EESPIRATOEY  SYSTEM. 

HEMOPTYSIS. 

(Bronchorrhagia,  Broncho-pulmonary  Hemorrhage.) 

Definition. — The  expectoration  of  blood. 

Etiology. — (1)  Vicarious  menstruation  (rare).  (2)  Trau- 
matism. (3)  Inflammatory  diseases  of  the  respiratory  tract, 
especially  phthisis  and  pneumonia.  (4)  The  rupture  of  an 
aortic  aneurism.  (5)  Obstruction  to  the  venous  circulation 
as  in  chronic  heart  and  liver  disease,  (6)  Malignant  disease 
of  the  lung.  (7)  A  dyscrasia  of  the  blood,  as  in  purpura,  the 
infectious  fevers,  haemophilia  (bleeder's  disease),  and  scurvy. 
(8)  It  occasionally  occurs  in  young  people  without  obvious 
cause. 

Symptoms. — Sometimes  the  bleeding  is  preceded  by  cough, 
dyspnoea,  or  substernal  warmth  or  tenderness,  but  often  there 
is  no  premonition,  and  the  first  indication  is  the  presence  of  a 
warm  salty  fluid  in  the  mouth.  The  blood  is  generally  raised 
by  coughing,  and  is  bright  red  and  frothy.  It  is  alkaline  in 
reaction,  and  intimately  mixed  with  air  and  mucus.  The 
hemorrhage  is  rarely  profuse  unless  it  results  from  the  rupture 
of  an  aortic  aneurism  or  the  ulceration  of  a  large  vessel  in  ad- 
vanced phthisis.  Auscultation  of  the  chest  reveals  bubbling 
rales.  The  subsequent  expectorations  are  tinged  with  blood, 
and  if  much  is  swallowed  it  may  excite  vomiting  or  pass  into 
the  intestine  and  impart  a  tarry  appearance  to  the  stools. 

Diagnosis. — HcBinoptysis  must  be  distinguished  from  hcema- 
temesis: — 


HEMOPTYSIS. 

History  of  some  chest  disease. 

The  blood  is  ejected  by  coughing. 
The    blood    is    bright    red    and 

frothy. 
The  blood  is  mixed  with  sputum. 
The  blood  is  alkaline  in  reaction. 
The    subsequent    expectorations 

are  tinged  with  blood,  and  the 

stools  are  rarely  tarry. 
Auscultation  reveals  rales. 


H^MATElilESIS. 

History  of  some  abdominal  dis- 
ease. ' 

The  blood  is  ejected  by  vomiting. 

The  blood  is  dark,  and  dense  or 
clotted. 

The  blood  is  mixed  with  food. 

The  blood  is  acid  in  reaction. 

The  subsequent  expectorations 
contain  no  blood,  and  the  stools 
are  frequently  tarry. 

Auscultation  gives  negative  re- 
sults. 


PULMONARY  APOPLEXY.  199 

Peognosis. — Heemoptysis  is  rarely  the  cause  of  death  in 
the  disease  in  which  it  occurs.  In  phthisis  the  symptoms 
often  improve  aft«r  a  moderate  hemorrhage.  On  the  other 
hand,  in  aneurism,  advanced  phthisis,  and  abscess  and  gan- 
grene of  the  lung,  the  bleeding  may  prove  fatal. 

Treatment. — Absolute  rest  and  the  avoidance  of  excite- 
ment. The  shoulders  should  be  elevated  ;  an  ice-bag  may  be 
placed  on  the  chest,  and  pieces  of  ice  may  be  held  in  the  mouth, 
and  slowly  swallowed.  Morphine  is  generally  required  as  a 
sedative ;  it  may  be  given  hypodermically  with  ergotin  (gr. 
v-x)  or  with  the  fluid  extract  of  ergot  ("L  x-xx).  Gallic  acid 
(gr.  x-xx)  may  be  given  by  the  mouth.  Astringent  sprays 
are  useless.  A  saline  purge  may  act  beneficially  by  inviting 
blood  away  from  the  congested  organ.  A  firm  ligature  around 
one  or  both  legs  retards  the  flow  of  venous  blood,  and  so  aids 
in  arresting  the  hemorrhage. 

When  the  bleeding  is  not  profuse,  but  frequently  repeated, 
the  following  internal  remedies  are  efficient :  Acetate  of  lead 
gr.  ij  with  powdered  opium  gr.  ^,  gallic  acid  (gr.  x-xx),  fluid 
extract  of  hamamelis  (5j-5i\j)j  turpentine  (gtt.  x),  or — 

1^  Acid,  gallic,  ^iiss  ; 

Acid,  sulph.  aromat.,  f^j  ; 
Glycerin.,  f^ss  ; 
Aquae,  q.  s.  ad  f  ^iv — M. 
Sig. — A  tablespoonful  tlirice  daily. 

PULMONARY  APOPLEXY. 

(Hemorrhagic  Infarction  of  the  Lung.) 

Definition. — An  effusion  of  blood  into  the  pulmonary 
tissues. 

Etiology. — It  may  result  from  degeneration  of  the  pul- 
monary vessels,  but  it  is  most  frequently  due  to  an  embolism 
in  one  of  the  branches  of  the  pulmonary  artery.  The  em- 
bolism is  usually  a  portion  of  thrombus  which  has  formed  in 
the  heart  or  in  one  of  the  systemic  veins.  Occlusion  of  the 
vessel  causes  a  backward  flow  of  blood,  the  part  becomes  en- 
gorged, and  effiision  follows. 


200  DISEASES   OF  THE  EESPIRATOEY  SYSTEM. 

Pathology.  —  The  infarction  is  usually  located  in  the 
periphery  of  the  lung ;  it  is  conical  in  shape  with  its  apex 
pointing  inwards.  The  portion  affected  is  airless,  and  reveals 
an  infiltration  of  dark  blood.  Microscopic  examination  shows 
a  dense  aggregation  of  blood-corpuscles-. 

If  it  does  not  prove  fatal,  absorption  and  subsequent  fibroid 
induration  result. 

Symptoms. — When  the  infarction  is  large  the  usual  symp- 
toms are  dyspnoea,  cough,  and  the  expectoration  of  dark  blood 
containing  few  air-bubbles.  These  symptoms  occurring  in 
chronic  heart-disease  are  especially  suggestive. 

Physical  Signs. — Very  large  infarctions  give  dulness  and 
bronchial  breathing. 

Treatment. — The  condition  itself  is  not  amenable  to  treat- 
ment.    Remedies  should  be  directed  to  the  primary  disease. 

CONGESTION  OF  THE  LUNGS. 

Active  Congestion. 

Etiology. — This  results  from  increased  afflux  of  blood  to 
the  lungs.  Hypertrophy  of  the  heart,  violent  exercise,  moun- 
tain-climbing, the  inhalation  of  irritants,  and  mental  excitement 
occasionally  produce  it.  It  is  an  associated  condition  in  all 
severe  inflammatory  diseases  of  the  lungs.  In  the  vast 
majority  of  cases  it  marks  the  initial  stage  of  croupous  pneu- 
monia. 

Pathology. — The  lung  is  bright  red  in  color,  heavy,  and 
less  ci'epitant.  When  incised  and  pressed,  copious  frothy 
blood  exudes. 

Symptoms.  —  Flushed  face ;  dyspnoea ;  short,  dry  cough, 
followed  by  tenacious  blood-streaked  expectoration ;  and  a 
rapid,  full  pulse.  Physical  examination  reveals  slight  dulness, 
crepitant  ri\les,  and  broncho-vesicular  breathing. 

Treatment. — Rest ;  liquid  diet ;  wet  cups  to  the  chest. 

Internally. — Veratrum  viride  and  a  saline  purge. 


CONGESTION  OF  THE  LUNGS.  201 

Passive  Congestion. 

Etiology. — This  results  from  obstrnction  to  the  flow  of 
blood  from  the  lungs  to  the  heart.  The  chief  cause  is  cardiac 
disease,  especially  fatty  degeneration,  dilatation,  and  mitral 
disease. 

Pathology, — The  lungs  are  dark  red  in  color,  and  often 
somewhat  oedematous.  "When  the  condition  has  lasted  a  long 
time,  the  organs  become  brown,  dense,  and  tough  (brown  in- 
duration). Microscopic  examination  •  reveals  a  dilatation  of 
the  capillaries,  an  overgrowth  of  connective  tissue,  free  pigment 
granules,  and  degenerative  changes  in  the  bloodvessels. 

Symptoms. — Dyspnoea ;  hard  cough  ;  mucous  expectoration 
containing  pigmented  cells.  Physical  examination  reveals 
rales,  slight  dulness,  and  feeble  breathing. 

Treatment. — Remedies  should  be  directed  to  the  under-, 
lying  cardiac  disease.  The  application  of  dry  cups  often  gives 
temporary  relief.     Saline  laxatives  may  prove  useful. 

Hypostatic  Congestion. 

(Hypostatic  Pneumonia,  Splenization  of  the  Lung.) 

Definition. — A  congestion  of  dependent  portions  of  the 
lungs  occurring  in  asthenic  diseases  which  necessitate  a  pro- 
tracted recumbent  position. 

Etiology. — It  is  generally  observed  in  low  fevers  and  in 
chronic  wasting  diseases.  (1)  Blood-dyscrasia,  (2)  a  weak 
heart,  and  (3)  a  recumbent  position  are  the  causal  factors. 

Pathology. — The  lungs  are  dark  red  and  oedematous  pos- 
teriorly. The  oedema  and  increased  amount  of  blood  render 
the  organs  more  solid  and  less  crepitant.  They  never  show 
the  granular  appearance  of  croupous  pneumonia. 

Symptoms. — Dyspnoea,  cough,  and  scanty  expectoration. 

Physical  examination  reveals  slight  dulness,  subcrepitant 
rales,  and  feeble  bronchial  breathing. 

Treatment. — Efforts  should  be  made  to  prevent  the  de- 
velopment of  hypostatic  pneumonia  in  asthenic  disease  by 
frequent  change  of  position,  and  the  timely  use  of  such  cardiac 


1^ 


202  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

stimulants  as  alcohol,  strychnine,  digitalis,  ammonia,  and  tur- 
pentine. When  already  present,  turpentine  stupes  or  dry  cups 
may  be  applied  externally,  and  one  or  more  of  the  above 
stimulants  administered  internally. 

•    ^.^ 

^  CROUPOUS  PNEUMONIA. 

(Lobar  Pneumonia,  Pneumonitis,  Lung  Fever.) 


Definition. — An  acute  specific  disease,  cbarkcterized  ana- 
tomically by  an  inflammation  of  the  lungs,  followed  by  a 
rapid  infiltration  of  their  alveoli ;  and  manifested  clinically  by 
high  fever,  cough,  dyspnoea,  "rusty"  sputum,  and  physical 
signs  indicative  of  consolidation. 

Etiology. — Age,  sex,  and  climate  exert  but  little  predis- 
posing influence.  Lowered  vitality  from  bad  hygiene  or  from 
some  pre-existent  disease,  like  diabetes,  Bright's  disease,  or  one 
of  the  infectious  fevers,  favors  its  development.  One  attack 
renders  the  patient  more  liable  to  subsequent  infection.  Alco- 
holism is  a  strong  predisposing  factor.  Exposure  to  cold  and 
wet  often  precipitates  the  attack. 

The  exciting  cause  is  unquestionably  a  microorganism,  pro- 
bably Fraukel's  diplococcus  pneumoniae. 

Pathology. — Anatomically  three  stages  have  been  recog- 
nized :  (1)  The  stage  of  congestion  ;  (2)  of  red  heijatization  ; 
(3)  of  gray  hepatization. 

^tage  1. — The  affected  portion  remains  distended  when  the 
chest  is  opened ;  it  is  of  a  deep-red  color,  and  is  more  resistant 
to  the  touch  than  the  normal  lung.  Od  section,  a  frothy  blood- 
stained serum  freely  exudes.  Microscopic  examination  reveals 
a  dilated  and  tortuous  condition  of  the  capillaries,  swelling  of 
the  alveolar  cells,  and  a  slight  corpuscular  exudate. 

Stage  2. — The  hepatized  portion  is  increased  in  volume,  is 
quite  firm,  is  of  a  dark-red  color,  and  so  heavy  that  it  sinks 
in  water.  It  is  very  friable,  and  the  torn  surface  presents  a 
granular  appearance  fi'om  the  projection  of  the  fibrinous  plugs 
in  the  alveoli. 

Microscopic  examination  reveals  a  mesh  of  coagulated  fibrin, 
enclosing  numerous  red  blood-corpuscles  and  some  leucocytes ; 


CEOUPOtrS  PNEUMONIA.  203 

the  latter  are  also  noted  in  the  interlobular  tissue.    In  sections 
properly  treated  the  diplococcus  is  detected. 

Stage  3. — The  red  color  gives  place  to  a  mottled  gray,  and 
the  solidified  lung  begins  to  soften.  The  change  in  color  is 
due  to  the  compression  of  the  capillaries,  to  the  disappearance 
of  red  corpuscles  and  their  replacement  by  leucocytes,  and  to 
fatty  degeneration  of  some  of  the  elements. 

In  favorable  cases  resolution  occurs  before  gray  hepatization 
has  far  advanced,  the  exudation  being  removed  by  absorption 
and  expectoration. 

In  unfavorable  cases  the  consolidated  lung  may  become  in- 
filtrated with  pus  (Purulent  infiltration) ;  it  may  become 
gangrenous ;  or,  very  rarely,  it  may  become  the  seat  of  fibroid 
induration  (Chronic  interstitial  pneumonia). 

Death  may  result  early  in  the  disease  from  the  generated 
blood-poisons,  or  from  rapid  diminution  of  the  respiratory 
surface. 

The  consolidation  usually  begins  at  the  base  and  extends 
upwards.  The  most  frequent  seat  is  the  lower  lobe  of  the 
right  lung.  The  bronchi  and  the  adjacent  pleura  are  involved 
in  the  inflammatory  process. 

Symptoms. — The  disease  usually  begins  with  a  decided 
chill  and  a  sharp  pain  in  the  side,  followed  by  a  rapid  rise  of 
temperature ;  the  latter  often  attains  its  maximum  (104°-105°) 
in  twenty-four  hours,  and  generally  continues  high,  with  slight 
diurnal  remissions,  until  the  ninth  day,  when  it  fallsj^ycrisis, 
frequently  reaching  the  norm"15y  the  tenth  day.  Occasionally  -^ 
the  temperature  falls  by  lysis.  There  is  marked  dyspnoea ;  -* 
the  respirations  are  shallow  and  rapid,  ranging  from  40  to  80 
per  minute,  thus  making  the  ratio  between  respiration  and  the 
pulse  1  to  3  or  1  to  2.  Cough  is  a  prominent  symptom  ;  at 
first  it  is  short  and  dry,  but  later  it  is  accompanied  by  bloody 
("rusty"),  translucent,  and  tenacious  sputa.  Microscopically 
the  sputum  contains  red  blood-corpuscles,  their  free  pigment, 
pus-corpuscles,  diplococci,  and  other  microorganisms.  The 
face  is  flushed ;  the  lips  are  cyanosed  and  often  the  seat  of  an 
herpetic  eruption  ;  the  tongue  is  heavily  furred ;  the  bowels 
are  constipated ;    and   the  urine  is  scanty,  high-colored,  de- 


^ 


204  DISEASES   OF  THE  EESPIEATORY   SYSTEM. 

ficient  ill  chlorides,  and  often  slightly  albuminous.  In  severe 
cases  delirium  is  rarely  absent. 

Physical  Signs.    Inspection. — Diminished  expansion,  but 

no  bulging  of  the  interspaces  or  displacement  of  the  apex-beat. 

Palpation.  —  Diminished    expansion   and    increased   vocal 

fremitus. 

/     Percussion. — At  the  onset  there  may  be  tympany  over  the 

affected  area  from  diminished  intra-pulmonary  tension.     As 

consolidation  advances   the   note   becomes    remarkably   dull. 

^Exaggerated  resonance  is  noted  around  the  hepatized  areas. 

Auscultation. — In  the  stage  of  congestion  fine  crepitant  rales 
are  heard  at  the  end  of  forced  inspiration ;  they  probably 
result  from  the  forcible  separation  of  adherent  vesicular  walls, 
and  disappear  when  the  lung  becomes  solidified.  Auscultation 
then  detects  increased  vocal  resonance,  and  harsh  breathing 
which  is  prolonged,  high-pitched,  and  tubular  in  expiration 
(bronchial). 

During  resolution  the  softened  exudate  produces  fine  moist 
4-^  rales — the  redux-crepitus. 

*  Atypical  Cases.     Senile  Pneumonia. — The  symptoms  often 

develop  insidiously ;  the  temperature  may  not  be  high  ;  the 
pulse  may  not  be  accelerated ;  expectoration  is  often  absent ; 
the  signs  are  not  marked ;  delirium  is  common ;  weakness  is 
extreme;  and  death  from  exhaustion  is  the  most  frequent 
termination. 

Pneumonia  in  Children. — It  is  often  ushered  in  with  con- 
vulsions.    Headache,  delirium,  stupor,  and  coma  are  promi- 
nent symptoms,  so  that  the  disease  may  simulate  meningitis. 
The  temperature  is  very  high ;  expectoration  is  often  absent. 
The  disease  frequently  begins  at  the  apex  of  the  lung. 
/        Typhoid  Pneumonia. — Pneumonia  associated  with  typhoid 
I    symptoms,  —  headache,    muttering   delirium,   stupor,    a   dry, 
\   brown  tongue,  subsultus  tendinum,  carphologia,  a  rapid,  weak 
\  pulse,  and  hi^h  fever  which,  in  favorable  cases,  falls  by  lysis. 
The  expectoration  is  often  like  prune-juice.  ' 

Pneumonia  of  Drunhards. — The  onset  is  gradual ;  the  ex- 
pectoration is  like  prune-juice ;  the  temperature  is  not  high, 
but  a  violent  maniacal  delirium  commonly  develops  and  is 
followed  by  death  from  exhaustion. 


CROUPOUS  PNEUMONIA.  205 

Complications, — Pleurisy,  pericarditis,  endocarditis,  oedema 
of  the  lungs,  delayed  resolution  (consolidation  may  last  five  or 
six  weeks,  and  then  disappear),  abscess  of  the  lung,  gangrene 
of  the  lung,  and  chronic  interstitial  pneumonia. 

Diagnosis.  Pleurisy. — Here  the  initial  chill  is  not  so 
marked  ;  the  fever  is  not  so  high  nor  the  pulse  so  rapid  ;  and 
there  is  no  "  rusty"  sputum  ;  but  bulging  and  displacement  of 
the  apex-beat  are  often  noted  on  inspection  ;  tiie  percussion-dul- 
ness  may  change  with  the  posture  of  the  patient ;  vocal  reso- 
nance and  vocal  fremitus  are  diminished ;  and  the  breathing 
is  distant  and  weak. 

Acute  Phthisis. — Irregular  fever,  bacillus  tuberculosis  in  the 
sputum,  and  the  continuation  of  grave  symptoms  with  signs 
of  softening  after  the  ninth  or  tenth  day,  will  suggest  the 
diagnosis  of  tuberculosis. 

Pulmonary  CEklema. — Here  there  is  absence  of  chill,  fever, 
and  pain ;  the  expectoration  is  watery,  not  "  rusty ;"  both 
lungs  are  commonly  affected  ;  auscultation  reveals  abundant 
subcrepitant  rales  and  weak  breathing. 

Typhoid  Fever. — Typhoid  pneumonia  may  be  readily  mis- 
taken for  typhoid  fever  with  pneumonia ;  but  pneumonia  as  a 
complication  occurs  late  in  the  disease,  so  that  the  history  of 
the  onset  gives  much  assistance. 

The  rose-red  rash  will  indicate  typhoid  fever. 

Prognosis. — In  patients  previously  healthy,  the  prognosis 
is  good.  At  the  extremes  of  life  the  outlook  is  grave.  In 
drunkards  the  disease  is  especially  fatal. 

In  individual  cases,  a  very  high  fever,  great  dyspnoea  and 
cyanosis,  rapidly  increasing  consolidation,  involvement  of  both 
lungs,  and  a  dark  sputum  are  unfavorable  factors. 

The  average  mortality  is  20  per  cent. 

Treatment. — Absolute  rest.  A  liquid  or  semi-liquid  diet 
(milk,  koumiss,  eggs,  broths,  beef  juice).  The  chest  should  be 
enveloped  in  a  cotton  jacket  covered  with  oiled  silk. 

Although  pneumonia  is  an  infectious  disease  which  produces 
widespread  disturbance  in  the  economy,  the  immediate  danger 
is  often  obstruction  to  the  pulmonary  circulation ;  so  that  in 
the  stage  of  congestion,  when  the  pulse  is  full  and  strong, 
veratrum  viride  (TIX  iij-v  of  the  fluid  extract  every  hour  until 


206  DISEASES   OF  THE   RESPIKATORY  SYSTEM. 

the  pulse  softens)  is  a  valuable  remedy.  It  depresses  the 
heart,  dilates  the  systemic  vessels,  and  so  invites  blood  away 
from  the  engorged  lung.  In  the  very  robust,  venesection  may 
be  substituted  for  veratrum. 

In  consolidation,  the  right  ventricle  is  subjected  to  a  strain 
and  there  is  danger  of  heart  failure ;  hence  cardiac  stimulants 
are  indicated  in  this  stage.  The  tincture  of  digitalis  (gtt.  x 
every  two  or  three  hours,  being  guided  by  the  pulse)  may  be 
given  by  the  mouth  ;  when  the  stomach  is  irritable,  the  drug 
should  be  administered  hypodermically.  Strychnine  (gr.  ■^) 
is  also  of  great  value  as  a  cardiac  and  respiratory  stimulant. 
Ammonia  is  useful  in  some  cases,  and  either  the  aromatic  spir- 
its or  the  carbonate  may  be  employed.  The  inhalation  of 
oxygen  sometimes  gives  much  relief.  Marked  cyanosis  with 
engorgement  of  the  right  ventricle  is  an  indication  for  vene- 
section. 

As  a  general  stimulant  and  food,  alcohol  is  often  indicated. 
In  typhoid  pneumonia  turpentine  (TTl  v)  may  be  associated 
with  the  alcohol. 

Pain  may  be  relieved  by  opium,  or  by  the  application  of 
wet  cups,  dry  cups,  an  ice-bag,  or  hot  fomentations. 

Delirium. — Apply  an  ice-bag  to  the  head,  and  administer 
bromide  of  potassium,  hyoscine,  musk,  or  camphor  internally. 
When  the  delirium  is  associated  with  high  fever,  a  cold  pack 
or  tepid  bath  will  often  control  it. 

Pyrexia. — Occasionally,  high  fever  will  require  treatment ; 
sponging,  a  cold  pack,  or  a  cold  bath  (80°)  may  be  employed. 
Antipyrin  (gr.  vj)  is  a  safe  and  efficient  remedy. 

Convalescence  should  be  guarded,  and  such  tonics  as  iron, 
quinine,  strychnine,  and  cod-liver  oil  will  be  found  useful  resto- 
ratives. 

In  delayed  resolution,  small  blisters  may  be  applied  over  the 
affected  areas,  and  iodide  of  potassium  may  be  administered 
internally.     Thus  : — 

Potass,  iodid.,  gj  ; 
Ammon.  chlor.,  giss  ; 

Mist,  glycyrrhizee  comp.,  f^vj. — M.    (Da Costa.) 
Sig. — Tablespoouful  four  times  a  day. 


CATAEEHAL  PNEUMONIA.  207 

CATAJRRHAl.  PNEUMONIA. 

{Broncho-pneumonia,  Lobular  Pneumonia,  Insular  Pneumonia.) 

Definition. — An  inflammation  of  the  terminal  bronchioles 
and  air-vesicles,  characterized  anatomically  by  scattered  areas 
of  consolidation  which  are  composed  almost  entirely  of  leuco- 
cytes and  desquamated  epithelium ;  and  manifested  clinically 
by  moderately  high  and  irregular  fever,  dyspnoea,  cough,  and 
physical  signs  indicative  of  insular  consolidation. 

Etiology. — The  disease  is  generally  secondary  to  bronchitis, 
and  the  causes  which  predispose  to  an  extension  of  the  inflam- 
mation from  the  bronchi  to  the  air-vesicles  are :  Childhood 
and  old  age ;  the  infectious  fevers,  especially  measles,  whoop- 
ing-cough, diphtheria,  and  influenza ;  and  low  vitality. 

Another  group  of  cases  results  from  the  aspiration  of  mucus, 
pus,  or  particles  of  food  into  the  smaller  bronchi.  This  is 
liable  to  occur  from  any  cause  which  renders  expectoration  im- 
perfect, as  the  coma  of  apoplexy,  the  stupor  of  typhoid  fever, 
bulbar  palsy,  tracheotomy,  and  advanced  paretic  dementia. 

Pathology. — As  a  rule,  both  lungs  are  involved.  On 
section,  small  projecting  areas  of  consolidation  are  noted  here 
and  there  around  the  finer  bronchioles.  Recent  patches  are 
reddish-brown  in  color,  firm,  and  smooth  or  finely  granular  ; 
later  they  become  grayish  and  soft.  The  terminal  bronchi 
are  filled  with  purulent  matei'ial. 

In  addition  to  these  solidified  areas,  there  are  other  small 
patches  of  collapsed  lung  which  are  airless,  firm,  and  bluish- 
red  in  color.  The  collapse  has  resulted  from  occlusion  of  the 
bronchus,  and  closely  resembles  consolidation ;  but  it  can,  as 
a  rule,  be  overcome  when  inflation  is  practised  by  means  of  a 
blowpipe  inserted  in  the  supplying  bronchus. 

Microscopic  examination  reveals  an  exudate  in  the  terminal 
bronchi  and  air-cells,  which  is  composed  of  leucocytes  and  des- 
quamated epithelium  in  various  stages  of  degeneration. 
The  walls  of  the  bronchi  are  also  infiltrated  with  leucocytes. 

When  compared  with  croupous  pneumonia,  the  contrast  is 
striking.  In  the  latter  the  lung  is  involved  en  masse  ;  the  con- 
solidation is  distinctly  granular,  and  is  composed  of  red  blood- 


208  DISEASES  OF   THE   EESPIRATOEY  SYSTEM. 

corpuscles,  white  blood-corpuscles,  fibrin,  and  diplococci ;  the 
lining  epithelium  is  but  slightly  involved ;  and  the  walls  of  the 
bronchi  are  not  infiltrated  with  leucocytes. 

Termijstations. — (1)  Resolution  ;  the  exudate  undergoes 
fatty  degeneration  and  is  removed  by  absorption  or  expectora- 
tion. (2)  Tuberculosis.  Termination  in  phthisis  is  quite  com- 
mon ;  doubtless  in  many  cases  the  disease  was  primarily  tuber- 
culosis, and  in  others  the  exudate  became  a  good  soil  for  the 
development  of  tubercle  bacilli.  (3)  Abscess  or  gangrene ; 
these  terminations  are  rare  except  in  pneumonias  resulting 
from  aspiration. 

Symptoms. — The  symptoms  are  often  masked  by  the  pri- 
mary disease.  The  onset  is  usually  gradual,  and  is  character- 
ized by  prostration,  cough,  and  fever.  The  last  is  moderately 
high  and  very  irregular  (101°-104°).  The  dyspnoea  is 
marked,  and  the  respirations  are  rapid — 50  to  80  per  minute  ; 
the  pulse  is  greatly  accelerated — 120  to  180  per  minute; 
cough  is  painful  and  accompanied  by  a  muco-purulent  ex- 
pectoration which  is  rarely  blood-streaked.  The  face  is  usu- 
ally pale  and  anxious,  and  the  lips  blue. 

Physical  Signs. — As  the  areas  of  consolidation  are  gene- 
rally small  and  scattered,  the  physical  signs  are  not  marked. 

Inspection  reveals  evidences  of  dyspnoea, — lividity,  playing 
of  the  nostrils,  prominence  of  the  sterno-cleido-mastoids,  and 
retraction  of  the  base  of  the  chest. 

Palpation  usually  gives  negative  results. 

Percussion  may  reveal  areas  of  dulness  in  one  or  both  lungs. 

Auscultation  reveals  fine  sibilant  (whistling)  or  subcrepitant 
rS.les,  and  areas  over  which  the  breathing  is  tubular,  or  bron- 
chial. 

Diagnosis. — The  following  table  will  show  the  clinical 
differences  between  catarrhal  and  croupous  pneumonias: — 


CATAEEHAL   PNEUMONIA. 


209 


Cause  .  .  . 
Onset  .  .  . 
Fevek  .     .     . 

expectokation 
Physical  Signs 


Catarrhal  Pneumonia. 

Usually  secondary  to  bron- 
cliitis. 

Gradual,  a  cliill  generally 
absent. 

Moderately  high,  very  ir- 
regular, and  ending  by 
lysis  after  an  indefinite 
period. 

Muco-purulent. 

A  bilateral  disease.  Phy- 
sical signs  are  indistinct 
and  indicate  scattered 
areas  of  consolidation. 


Croupous   Pneumonia. 
A  primary  disease  excited 

by  the  diplococcus. 
Abrupt  onset  with  a  cliill. 

High,  regular,  and  ending 
by  crisis  at  the  eighth  or 
ninth  day. 

"  Rusty,"  translucent,  and 
tenacious. 

A  unilateral  disease.  Phy- 
sical signs  are  distinct 
and  indicate  a  large  and 
uniform  consolidation. 


Aeute  Phthisis. — In  this  disease  there  -is  a  tuberculous 
broncho-pneumonia  which  is  difficult  to  distinguish  from  sim- 
ple broncho-pneumonia.  A  family  history  of  tuberculosis,  an 
extensive  involvement  of  the  apices,  bubbling  rales  indicating 
softening,  long  duration,  and  bacilli  and  elastic  fibres  in  the 
sputa  are  the  diagnostic  phenomena  of  phthisis. 

Bronchitis. — In  simple  bronchitis  the  fever  is  not  high,  the 
dyspnoea  is  rarely  marked,  prostration  is  usually  absent,  and 
there  are  no  physical  signs  indicating  consolidation. 

Capillary  Bronchitis  always  precedes  catarrhal  pneumonia, 
and  the  diagnosis  of  the  two  is  often  impossible.  The  absence, 
in  the  former,  of  physical  signs  indicating  consolidation  is  the 
only  diagnostic  factor. 

Peognosis. — Always  guarded.  In  the  very  young,  very 
old,  and  debilitated  the  disease  is  commonly  fatal.  Many 
recover  from  the  pneumonia  following  the  infectious  fevers. 
Aspiration-pneumonia  is  commonly  fatal.  The  mortality  is 
difficult  to  estimate,  for  acute  phthisis  is  often  diagnosed 
catarrhal  pneumonia ;  it  is  probably  greater  than  in  croupous 
pneumonia,  and  varies  from  30  to  60  per  cent.  The  duration 
is  from  one  to  three  weeks ;  a  longer  duration  would  suggest 
tuberculosis. 

Teeatment. — The  disease  can  often  be  prevented  by  care- 
fully protecting  patients  suffering  from  bronchitis  and  infec- 
14 


210  DISEASES   OF  THE   EESPIRATORY  SYSTEM. 

tious  fevers.  In  the  latter  it  is  also  essential  that  the  naso-pha- 
rynx  should  be  kept  clean  with  some  mild  antiseptic  solution. 

The  room  should  be  well  ventilated,  but  free  from  draft, 
and  the  temperature  should  be  kept  uniformly  at  70°.  A 
moist  atmosphere  is  desirable,  and  an  apparatus  for  producing 
steam  may  be  improvised.  Tincture  of  iodine  may  be  applied 
locally,  and  the  chest  enveloped  in  a  cotton  jacket. 

The  diet  should  be  liquid  or  semi-liquid,  and  may  include 
milk,  junket,  koumiss,  eggs,  broths,  and  beef-juice.  Stimu- 
lants, wine  or  brandy,  are  usually  required  to  combat  the 
extreme  prostration. 

At  the  onset  a  laxative  should  be  administered,  and  calomel 
may  be  selected  (gr.  ^  every  hour  until  it  operates). 

Stimulating  expectorants  are  nearly  always  indicated,  and 
chloride  of  ammonium,  carbonate  of  ammonium,  squills,  or 
senega  may  be  employed. 

1^  Ammon.  chloridi,  gr.  1 ; 
Spt.  setheris  nitrosi,  fgss  ; 
Syr.  senegse,  f^iiss  ; 

Tinct.  cardamom,  comp.  et  aquse,  aa  q.  s.  ad  f§ij. 

— M. 
Sig. — A  teaspoonful  every  two  or  three  hours  to  a  child  of  three 
years. 

Or— 

^   Ammon.  carb.,  gr.  xxiy ; 
Syr.  tolu.,  f^vj  ; 
Spt.  vini  gal.,  f  ^iij  ; 
Syr.  senegse,  f  ^iijss  ; 
Syr.  acacise,  q.  s.  ad  fsiij. — M. 

(GooDHART  and  Starr.) 
Sig. — Teaspoonful  every  two  hours  to  a  child  of  two  or  three  years. 

Strychnine  is  often  invaluable  as  a  respiratory  and  cardiac 
stimulant ;  for  an  adult,  gr.  -^q  may  be  given  three  or  four 
times  daily. 

The  accumulation  of  mucus  in  the  bronchial  tubes,  indicated 
by  extreme  cyanosis,  a  weak  pulse,  and  bubbling  rsiles,  will 
call  for  an  emetic ;  wine  of  ipecac  (3j-^ss),  or  apomorphine 
(for  an  adult  gr.  ^L)  ™ay  be  selected.  Nervous  symptoms — 
restlessness,  delirium,  etc. — will  often  be  relieved  by  a  cold 
pack  or  by  a  cold  bath.     Hyoscine,  bromide  of  potassium,  or 


CHEONIC  INTEESTITIAL  PNEUMONIA.  211 

chloral  in  small  doses  may  be  required.     In  children  the  fol- 
lowing suppository  is  often  very  efficient : — 

J^:  Pulv.  asafoetidae,  Sj  ; 

Quininse  sulph.,  gr.  xxx  ; 

01.  theobromatis,  q.s. — M.    (Pepper.) 
Ft.  in  suppos.  'No.  xii.     (Child's  size.) 
Sig.— One  every  three  or  four  hours  for  a  child  of  five  years. 

In  delayed  resolution  counter-irritants  should  be  applied  to 
the  affected  areas,  and  iodide  of  potassium  should  be  adminis- 
tered internally. 

Convalescence  must  be  guarded ;  tonics  like  cod-liver-oil, 
iron,  arsenic,  and  hypophosphites  are  useful  restoratives.  A 
change  of  scene  is  desirable. 

CHRONIC  INTERSTITIAL.  PNEUMONIA. 

(Cirrhosis  of  the  Lung,    Chronic  Pneumonia,   Pulmonary 
Induration. ) 

Definition. — A  chronic  disease  of  the  lung,  characterized 
by  an  overgrowth  of  fibrous  tissue. 

Etiology. — It  is  a  rare  sequel  of  croupous  pneumonia.  It 
is  commonly  found  associated  with  tubercles  in  fibroid  phthisis. 
The  overgrowth  of  connective  tissue  is  sometimes  induced  by 
an  old  fibrinous  pleurisy.  It  may  be  an  expression  of  syphilis. 
It  arises  primarily  from  the  constant  inhalation  of  irritating 
dusts,  as  stone-dust  (Chalicosis),  coal-dust  (Anthracosis), 
metal-dust  (Siderosis). 

Pathology. — When  the  thorax  is  opened  the  lung  is  found 
retracted  and  the  heart  displaced.  The  organ  is  tough,  firm, 
and  more  or  less  airless.  Section  shows  an  overgrowth  of 
fibrous  tissue,  and  usually  inflammation  and  considerable  dila- 
tation of  the  bronchi. 

Symptoms. — Moderate  dyspnoea  and  chronic  cough;  the 
expectoration  may  be  slight,  but  often  it  is  profuse,  and  fetid 
from  having  been  retained  in  bronchiectatic  cavities.  There 
is  no  fever,  and  the  general  health  may  be  well  preserved  for 
many  years. 

Physical  Signs.  —  Inspection  reveals  retraction  of  the 
affected  side  and  displacement  of  the  apex-beat. 


212  DISEASES  OF  THE  KESPIEATOEY  SYSTEM. 

Percussio7i  often  yields  dulness ;  but  over  saccular  dilata- 
tions of  the  bronchi  there  may  be  hyper-resonance. 

AusGultation.  —  The  vocal  resonance  is  increased  and  the 
breathing  is  often  bronchial  or  cavernous. 

Diagnosis.  Fibroid  Phthisis. — Involvement  of  both  lungs, 
bacilli  in  the  sputa,  and  fever  would  indicate  fibroid  phthisis. 

Prognosis. — Incural)le.  The  duration  is  from  ten  to  twenty 
years. 

Treatment.  —  Palliative.  It  consists  in  good  hygienic 
regulations  and  the  use  of  remedies  directed  to  the  bronchi- 
ectasis. 

GAl^GRENE  OF  THE  LUNG. 

Definition. — A  putrefactive  necrosis  of  the  lung. 

Etiology. — Gangrene  is  not  a  primary  condition,  but  is 
secondary  to  some  inflammatory  disease  of  the  lung.  It  is  ex- 
cited by  the  entrance  of  bacteria  of  putrefaction,  but  unless  the 
system  is  considerably  reduced  in  vitality  the  tissues,  even 
though  diseased,  show  wonderful  resistance,  and  escape  putre- 
faction. 

Pneumonia,  especially  aspiration-pneumonia,  phthisis,  pres- 
sure of  morbid  growths,  bronchiectasis,  abscess,  and  hemor- 
rhagic infarction  following  embolism  of  the  pulmonary  artery 
are  the  predisposing  pulmonary  conditions ;  and  Bright's  dis- 
ease, alcoholism,  the  infectious  fevers,  and  particularly  diabetes, 
by  lowering  the  vitality,  render  these  conditions  operative. 

Pathology. — The  process  may  be  circumscribed  or  diffuse, 
most  frequently  the  former.  The  aifected  part  is  converted 
into  a  greenish-black,  soft  mass,  having  an  extremely  fetid  odor. 
When  the  softened  material  has  been  expectorated  there  is  left 
behind  a  cavity  with  ragged  walls,  containing  a  foul-smelling 
liquid.  The  tissues  around  the  cavity  are  inflamed  and  oede- 
matous. 

Symptoms. — The  symptoms  of  gangrene  are  associated  with 
the  original  disease.  Cough,  dyspnoea,  moderate  fever,  and 
great  prostration  are  generally  present. 

The  expectoration  is  characteristic ;  it  is  profuse,  and  has  a 
penetrating  offensive  odor.     When  allowed  to  stand  in  a  glass 


ABSCESS  OF  THE  LUNG.  213 

vessel  it  separates  into  three  layers  :  a  frothy  layer  on  top,  a 
serous  layer  in  the  middle,  through  which  hang  strings  of  pus, 
and  at  the  bottom  a  layer  of  reddish-green  purulent  material. 
Altered  blood  may  give  it  the  appearance  of  prune-juice. 
Microscopically  it  contains  shreds  of  tissue,  crystals  of  fatty 
acids,  crystals  of  hsematoidin,  and  all  sorts  of  bacteria. 

Physical  examination  may  reveal  bubbling  rales,  and  later 
cavernous  breathing,  pectoriloquy,  and  localized  tympany  on 
percussion. 

Prognosis. — Grave.  Death  usually  results  from  exhaus- 
tion, but  occasionally  from  hemorrhage  or  pyo-pneumothoi'ax. 

Treatment. — Nutritious  food,  and  quinine,  strychnia,  and 
alcoholic  stimulants  will  be  required  to  support  the  system. 

The  offensive  odor  of  the  breath  may  be  destroyed  by  car- 
bolic acid  (gr.  j  every  four  hours)  internally,  or  by  inhalations 
of  carbolic  acid  or  creosote.  Turpentine  ("^v  every  three, 
hours)  has  been  recommended  as  a  stimulant  and  antiseptic. 
When  the  patient's  strength  will  permit,  surgical  interference 
offers  the  best  chance  of  cure. 

ABSCESS  OF  THE  LUNG. 

Definition. — Circumscribed  suppuration  of  the  lung. 

Etiology. — (1)  It  is  rarely  a  sequel  to  pneumonia.  (2) 
Multiple  abscesses  are  often  embolic,  and  result  from  pyaemia. 
(3)  Foreign  bodies  in  the  lungs — something  swallowed  or  an 
hydatid  cyst — may  excite  suppuration.  (4)  External  abscesses 
sometimes  rupture  into  the  lung,  as  an  empyema,  hepatic  ab- 
scess, or  suppurating  mastitis. 

Symptoms. — High  and  irregular  fever,  rigors,  sweats,  and 
pallor  indicate  suppuration.  Dyspnoea,  cough,  and  purulent 
offensive  sputa  containing  shreds  of  lung  tissue  are  the  pul- 
monary symptoms.  Physical  examination  may  reveal  bub- 
bling rales,  and  later,  cavernous  breathing  and  pectoriloquy. 
Multiple  embolic  abscesses  are  rarely  recognized  during  life. 

Prognosis. — Many  cases  following  pneumonia  and  the 
rupture  of  external  abscesses  into  the  lung  recover.  Embolic 
abscesses  generally  prove  fatal. 


214  DISi!ASEg  of  THE  HESt'ltlATOfeY  SYSTEM. 

Treatment. — Nutritious  food  and  quinine,  strychnine,  aiid 
alcoholic  stimulants  will  be  required  to  support  the  system. 
The  abscess  should  be  opened  and  drained,  as  the  pleural  sac 
is  in  empyema. 

CEDEMA  OF  THE  LUNGS. 

Definition. — An  effusion  of  serous  fluid  into  the  air- 
vesicles  and  into  the  interstitial  tissue  of  the  lungs. 

Etiology. — Pulmonary  oedema  is  a  common  cause  of 
death  in  many  acute  and  chronic  diseases  which  end  by  heart- 
failure  and  the  accumulation  of  blood  in  the  lungs. 

It  is  frequently  noted  in  the  course  of  Bright's  disease  and 
cardiac  disease. 

A  local  pulmonary  oedema  is  often  found  around  pulmonic 
consolidations,  abscesses,  and  infarctions. 

Pathology. — The  lungs,  especially  the  dependent  portions, 
are  heavy,  red  in  color,  and  boggy  to  the  feel.  When  the 
affected  portion  is  incised  and  pressure  is  made,  an  abundant 
blood-stained,  frothy  serum  exudes. 

Symptoms. — Extreme  dyspnoea ;  rapid,  labored  breathing ; 
cough  with  frothy,  blood-stained  expectoration;  cyanosis;  and 
cold  extremities. 

Physical  Signs.  Inspection  reveals  evidences  of  dyspnoea — 
sitting  posture  and  prominence  of  the  auxiliary  muscles  of 
respiration. 

Percussion. — Dulness  over  the  bases. 

Auscultation. — Feeble  respiratory  murmur ;  subcrepitant  or 
bubbling  r§.les. 

Diagnosis.  Pneumonia. — The  absence  of  chill,  of  fever, 
of  "■  rusty"  tenacious  sputa,  of  pain,  and  of  signs  indicating 
consolidation  will  indicate  oedema. 

Capillary  Bronchitis. — The  fever  and  muco-purulent  expec- 
toration will  serve  to  distinguish  bronchitis  from  oedema. 

Prognosis. — Always  grave.  It  is  often  a  final  symptom 
of  some  pulmonary  disease.  When  not  advanced,  and  the 
conditions  are  favorable,  recovery  may  follow. 

Treatment. — When  there  is  much  cyanosis,  and  the 
patient's  strength  will  permit  it,  the  application  of  wet  cups 


PULMONARY   COLLAPSE.  215 

to  the  chest  or  bleeding  from  the  arm  is  of  great  value.  Hot 
fomentations  should  be  applied  to  the  chest.  Hydragogue 
cathartics  are  indicated.  Epsom  salts  in  concentrated  solu- 
tions, or  elaterium  (gr.  |),  may  be  selected.  Cardiac  stimulants 
like  ether,  alcohol,  ammonia,  digitalis,  and  especially  strych- 
nine, are  required,  and  may  be  given  hypodermically. 

^   Strychnin,  sulph.,  gr.  j  ; 
Aquse  destillat,,  f^j. 
Solve  et  sig. — ^15  minims  hypodermically  every  three  or  four  hdurs. 

Caffeine  is  a  useful  diuretic,  and  cardiac  and  respiratory 
stimulant. 

^  Caffein.  citratis,  gr.  xl ; 
Sodii  beazoat.,  giss. — M. 
Ft.  in  chart.  Ko.  xii. 
Sig. — One  every  two  or  three  hours 

PULMONARY  COLLAPSE. 

(Atelectasis.) 

Definition — An  absence  of  air  from  a  portion  of  the  lung. 

Etiology. — It  may  be  congenital  and  result  from  deficient 
respiration ;  in  these  cases  the  dependent  portions  of  both 
lungs  are  commonly  affected.  Acquired  atelectasis  results 
from  occlusion  of  a  bronchus  by  a  foreign  body  or  a  plug  of 
mucus,  as  in  capillary  bronchitis ;  or  from  compression  of  the 
lung  by  a  tumor  or  pleural  effusion. 

Symptoms. — "When  a  large  area  is  collapsed  in  some  pre- 
existing disease  like  capillary  bronchitis,  there  is  an  abrupt 
increase  in  the  dyspnoea  and  cyanosis,  without  a  corresponding 
rise  of  temperature.  Physical  examination  gives  negative 
results  except  over  extensive  collapse,  which  may  give  dulness 
on  percussion  and  weak  breathing  on  auscultation. 

Prognosis.- — This  depends  upon  the  extent  of  collajDse  and 
the  gravity  of  the  pre-existing  disease. 

Treatment. — In  congenital  atelectasis  apply  alternately 
hot  and  cold  sponges  to  the  spine ;  keep  up  the  external  tem- 
perature. If  these  measures  fail,  gently  inflate  the  lung  with 
a  catheter. 

In  the  acquired  varieties   direct  remedies  to  the   original 


216  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

disease.     Administer  cardiac  and  respiratory  stimulants  like 
ammonia,  and  produce  emesis  with  ipecac  or  alum. 

PULMONAKY  TUBERCULOSIS. 

(Phthisis,  Pulmonary  Consumption.) 

Definition. — A  specific  inflammatory  disease  of  the  lungs, 
caused  by  the  bacillus  tuberculosis  ;  characterized  anatomically 
by  a  cellular  infiltration  which  subsequently  caseates,  softens, 
and  leads  to  ulceration  of  the  lung  tissue ;  and  manifested 
clinically  by  wasting,  exhaustion,  fever,  and  cough. 

Etiology. — (1)  Residence  in  low,  damp,  and  badly-drained 
localities,  (2)  Heredity  (important).  (3)  Age;  all  ages,  but 
especially  between  twenty  and  thirty  years.  (4)  Occupations 
which  necessitate  the  breathing  of  impure  air  and  the  inhala- 
tion of  irritants  like    coal-dust,  stone-dust,  iron-filings,  etc. 

(5)  Catarrhal    inflammation    and   traumatism   of   the   lungs. 

(6)  Physique.     (7)  General  diseases  which  lower  the  vitality, 
as  diabetes,  hepatic  cirrhosis,  and  typhoid  fever. 

The  exciting  cause  is  the  bacillus  tuberculosis,  which  gains 
entrance  (1 )  by  direct  parental  transmission  (very  rare)  ;  (2)  by 
inhalation,  the  dust  of  dried  sputum  being  commonly  the 
medium  of  contagion ;  (3)  through  infected  food,  as  the  milk 
and  meat  of  tuberculous  cattle. 

Varieties.  —  (1)  Chronic  ulcerative  phthisis.  (2)  Acute 
phthisis.     (3)  Fibroid  phthisis. 

Pathology. — The  bacillus  tuberculosis  is  a  very  minute 
rod,  about  one-fourth  or  one-half  as  long  as  a  red  blood- 
corpuscle,  and  often  slightly  bent  and  beaded.  Its  detection 
depends  on  the  power  of  the  stained  bacillus  to  resist  the  de- 
colorizing effects  of  acids.  For  satisfactory  examination  a 
one-twelfth  oil-immersion  lens  is  required. 

The  lodgment  of  bacilli  in  the  terminal  bronchioles  of  the 
apex  excites  a  proliferation  of  the  fixed  cells,  which  become 
more  or  less  polygonal  in  shape.  The  new  cells  are  termed 
epithelioid,  ancl  frequently  contain  bacilli.  Giant  cells  are  often 
formed  by  a  fusion  or  overgrowth  of  these  cells. 

This  aggregation  of  new  cells  acts  as  an  irritant  and  is  soon 
surrounded  by  a  wall  of  leucocytes,  the  whole  forming  a  gray, 


fULMONARY  TtJBERCULOSiS.  21? 

translucent  mass — the  gray  tubercle  of  Laennec.  In  a  short 
time  the  bacilli  excite  a  coagulation-necrosis  which  starts  in 
the  centre,  sjoreads  to  the  j)eriphery,  and  converts  the  tubercle 
into  a  yellow,  cheesy  mass — the  yellow  tubercle  of  Laennec. 
The  degenerated  tubercles  fuse  and  form  the  uniform  cheesy 
masses  so  commonly  observed  at  the  autopsy.  At  this  stage 
one  of  two  things  may  occur :  The  mass  may  soften,  break 
into  a  bronchial  tube,  and  leave  behind  a  cavity  with  ulcerat- 
ing walls,  or  it  may  become  encapsulated  by  an  overgrowth  of 
connective  tissue  and  subsequently  calcified.  In  addition  to 
the  specific  process  other  secondary  changes  are  noted.  The 
lung  tissue  in  the  neighborhood  of  the  tuberculous  deposits  is 
often  the  seat  of  a  true  pneumonic  inflammation ;  the  connective 
tissue  is  always  more  or  less  proliferated ;  the  bronchial  tubes 
are  inflamed  ;  and  the  pleurae  over  the  affected  areas  are  nearly 
always  adherent. 

Chronic  ulcerative  phthisis  usually  begins  at  the  apices. 

Acute  phthisis  has  been  termed  phthisis  florida,  cheesy  pneu- 
monia, and  chronic  catarrhal  jmeumonia,  but  the  process  is 
invariably  tuberculous.  From  extreme  vulnerability  of  the 
tissues  a  lobe  or  whole  lung,  or  even  both  lungs,  are  rapidly 
infiltrated,  and  death  results  in  from  a  few  weeks  to  a  few 
months. 

In  some  cases  the  lung  is  solidified  by  a  dense  yellowish- 
gray  infiltration  composed  of  closely-aggregated  tubercles  ;  in 
others  the  consolidation  appears  in  more  or  less  discrete 
patches  which  have  had  their  origin  in  the  smaller  bronchial 
tubes ;  in  a  third  form  one  or  both  lungs  are  studded  with 
discrete  tubercles,  many  of  which  are  still  gray  and  trans- 
lucent. 

In  fibroid  phthisis  the  tissues  appear  to  be  resistant,  and 
the  process  is  limited  by  an  overgrowth  of  connective  tissue 
which  forms  dense  bands  around  the  tuberculous  foci.  This 
form  lasts  many  years. 

Chronic  Ulcerative  Phthisis.  Symptoms. — The  onset  is 
usually  insidious  and  marked  by  pallor,  gastric  disturbance, 
loss  of  flesh  and  strength,  and  by  a  dry,  hacking  cough  M^iich 
is  especially  noted  in  the  morning.  From  some  undue  ex- 
posure, the  cough  is  often  aggravated,  and  to  this  obstinate 


218  DISEASES  OF  THE  EESPIRAtOEY  SYSTEM. 

"  cold"  the  disease  is  usually  attributed.  In  some  cases,  the 
symptoms  appear  abruptly  with  hemorrhage  or  an  acute 
pleurisy. 

Slight  fever  and  acceleration  of  the  pulse  are  early  symptoms 
of  great  diagnostic  import.  The  temperature  is  marked  by  an 
evening  exacerbation,  during  which  the  face  is  flushed,  the 
eyes  bright,  and  the  mind  animated.  As  the  disease  ad- 
vances the  cough  becomes  troublesome  and  the  expectoration 
more  abundant.  In  well-developed  cases  the  expectoration  is 
greenish  in  color,  is  in  coin-shaped  plugs  (nummular),  is  heavy 
and  sinks  in  water,  is  often  blood-streaked,  and  on  microscopic 
examination  is  found  to  contain  bacilli  and  fibres  of  elastic 
tissue. 

Phthisis  is  in  itself  not  a  painful  disease,  but  the  associated 
dry  pleurisy  often  causes  much  suifering.  Haemoptysis  occurs 
at  all  stages,  but  the  profuse  hemorrhages  occur  late.  The 
blood  is  bright  red  in  color,  frothy,  and  mixed  with  mucus. 
Dyspnoea  is  not  a  marked  symptom,  and  its  absence  is  doubt- 
less due  to  the  gradual  development  of  the  disease.  Profuse 
sweating  during  sleep  is  a  troublesome  feature  of  advanced 
phthisis. 

The  final  stage  is  characterized  by  extreme  emaciation, 
weakness,  pallor,  high  remittent  or  intermittent  fever,  and 
oedema  of  the  feet.  The  mind  is  usually  clear,  and  peculiarly 
hopeful  to  the  end. 

Physical  Signs.  Inspection. — The  chest  is  usually  long 
and  flat ;  the  spaces  above  and  below  the  clavicles  are  sunken ; 
the  scapulse  are  prominent ;  and  the  ribs  are  oblique. 

There  may  be  flattening  or  less  expansion  over  one  apex. 

Palpation. — Diminished  expansion  and  increased  vocal  fre- 
mitus. * 

Percussion. — Dulness,  as  a  rule  ;  this  is  noted  earliest  above 
or  below  the  clavicles,  in  the  supraspinous  fossae,  between  the 
scapulse,  or  in  front  near  tli^  sternal  border. 

A  cavity,  or  vomica,  yields  tympany,  or  a  "  cracked-pot" 
resonance.  The  latter  can  be  more  clearly  demonstrated  when 
the  ear  is  placed  near  the  patient's  open  mouth. 

Auscultation. — In  the  early  stage  respiration  may  be  inaud- 
ible over  the  affected  area.     Later  the  breathing  is  harsh 


PULMONARY  TiTBEtlCULOSlS.  219 

and  the  expiration  prolonged  and  high-pitched  (bronchial). 
The  vocal  resonance  is  increased.  Crackling  rales  are  usually 
audible,  and  are  produced  by  liquid  in  the  small  tubes.  If 
not  present,  coughing  will  usually  develop  them.  Ausculta- 
tion over  cavities  may  detect  cavernous  or  amphoric  breathing, 
pectoriloquy,  and  large  gurgling  rales. 

Anomalous  Physical,  Signs. — The  vocal  fremitus  is 
diminished  when  there  is  much  pleural  thickening.  Normal 
resonance  or  hyper-resonance  may  replace  dulness  when  there 
is  much  emphysema  between  small  tuberculous  foci.  Weak 
breathing  may  replace  bronchial  or  cavernous  when  the  tubes 
or  cavity  are  filled  with  muco-pus.  The  signs  of  cavity  are 
sometimes  produced  by  consolidation  in  the  neighborhood  of  a 
large  bronchus. 

Acute  Phthisis. — Clinically  this  form  resembles  pneumonia, 
and  is  marked  by  a  chill,  high  fever,  rapid  pulse,  dyspnoea, 
sputum  at  first  rusty  and  then  purulent,  flushed  face,  profuse 
sweats,  and  the  signs  of  consolidation.  Instead  of  ending  by 
crisis  at  the  eighth  or  ninth  day  as  an  ordinary  pneumonia, 
the  symptoms  grow  rapidly  worse,  signs  of  softening  appear, 
the  sputum  shows  bacilli  and  elastic  fibres,  and  death  results 
in  from  a  few  weeks  to  a  few  months. 

Fibroid  Phthisis. — This  is  a  disease  of  long  duration.  It  is 
characterized  by  very  gradual  loss  of  flesh  and  strength  and 
by  an  abundant  muco-purulent  expectoration,  which  is  at 
times  fetid  from  being  retained  in  dilated  bronchi.  Dyspnoea, 
sweating,  and  fever  are  slight.  There  is  very  marked  retrac- 
tion on  the  affected  side  from  the  shrinking  of  the  fibrous  tis- 
sue ;  with  this  exception  the  physical  signs  are  similar  to  those 
of  ulcerative  phthisis. 

Complications  of  Phthisis. — Heemoptysis  ;  pneumonia  ; 
pleurisy ;  pneumothorax ;  stomatitis ;  obstinate  vomiting  induced 
by  cough ;  diarrhoea ;  amyloid  degeneration  of  the  viscera ;  fistula 
in  ano  (tuberculous);  and  secondary  tuberculosis  of  other  organs, 
especially  the  larynx,  cerebral  meninges,  and  peritoneum. 
^  Diagnosis. — Fever,  cough,  haemoptysis,  night-sweats,  ema- 
ciation, signs  of  consolidation,  and  bacilli  and  elastic  fibres  in 
the  sputum  are  the  diagnostic  phenomena. 


220  DISEASES  OF  THE  HESPIEATORY  SYSTEM. 

Prognosis. — Generally  unfavorable,  though  the  disease  is 
not  incurable.  The  accidental  discovery  of  calcified  tubercles 
at  autopsies  furnishes  abundant  evidence  of  spontaneous  cure. 
Many  improve  and  a  few  recover  under  well-directed  treatment. 

A  strong  hereditary  tendency,  a  bad  physique,  high  fever, 
advanced  consolidation,  involvement  of  both  lungs,  even  if 
slight,  unfavorable  surroundings,  and,  it  might  be  added,  a 
slender  purse,  render  the  prognosis  extremely  grave. 

Treatment.  Preventive.  —  Recognizing  the  infectious 
nature  of  the  disease,  the  following  prophylactic  measures 
should  be  observed  :  Sputa  of  consumptives  should  be  received 
in  suitable  vessels  containing  antiseptic  solutions,  and  subse- 
quently destroyed.  Cattle  should  be  rigidly  inspected,  and 
tuberculous  meat,  and  milk  of  tuberculous  cows  declared  un- 
marketable. Phthisical  mothers  should  not  nurse  their  off- 
spring. The  healthy  should  not  sleep  in  apartments  occupied 
by  those  affected. 

Personal  Hygiene. — Good  food,  fresh  air,  frequent  bathing, 
avoidance  of  exposure,  graduated  exercise,  residence  in  an 
elevated  locality,  a  dry,  well-ventilated  house,  and  plenty  of 
sleep  and  recreation. 

Curative  Treatment. — This  involves  two  objects:  (1)  The 
strengthening  of  the  patient's  vitality  and  resisting  power. 
(2)  The  destruction  or  disabling  of  the  tubercle  bacilli. 

General  Health. — The  diet  should  be  carefully  regulated. 
Nutrients  like  cod-liver  oil  (5ij — 3iv  two  hours  after  meals), 
malt,  and  h^'pophosphites  are  often  very  useful.  Mineral  acids 
and  bitters  may  be  required  to  stimulate  digestion.  Iron, 
quinine,  and  arsenic  are  sometimes  indicated ;  the  last,  when 
well  borne,  often  exerts  a  decidedly  favorable  influence.  Alco- 
hol in  many  cases  is  of  great  value,  but  the  danger  of  inducing 
the  habit  must  be  borne  in  mind.  Beer,  porter,  ale,  and  wine 
are  usually  the  most  desirable  preparations.  So  long  as  alcohol 
stimulates  the  appetite,  lowers  the  temperature,  and  strengthens 
the  pulse  it  does  good.  Its  results  should  be  carefully  noted, 
and  any  untoward  effects  will  call  for  its  immediate  withdrawal. 

Change  of  Climate. — This  offers  to  many  patients  the 
greatest  hope  of  cure.  As  a  rule,  a  high  altitude  should  be 
selected ;  the  atmosphere  should  be  dry  and  the  temperature 


PULMONAKY  TUBERCULOSIS.  221 

equable.  Personal  experience  must  decide  the  question  of 
temperature ;  generally,  patients  who  feel  better  in  summer 
will  do  well  in  a  warm  climate,  and  vice  versa.  The  physician 
should  have  some  knowledge  of  the  locality,  which  should 
afford  ordinary  conveniences,  without  being  too  crowded  with 
sufferers  similarly  afflicted. 

In  selected  cases,  a  sea  voyage  is  often  very  useful.  Accord- 
ing to  Douglas  Powell,  it  is  most  suitable  to  patients  in  the 
early  stages,  who  have  been  previously  healthy,  who  have 
overworked  nervous  systems,  and  in  whom  the  disease  is 
more  or  less  quiescent. 

Specific  Treatment. — The  injection  of  iodine,  carbolic  acid, 
etc.  into  phthisical  lungs,  as  recommended  by  Mosler,  Thomp- 
son, and  Pepper,  has  not  given  encouraging  results.  Koch's 
tuberculin  has  been  shown  to  be  either  negative  or  deleterious 
in  its  effects.  Of  the  sjjecial  remedies  which  have  been  recon^- 
mended,  creosote  or  one  of  its  derivatives  alone  holds  a  prom- 
inent position  in  the  therapy  of  phthisis.  It  may  be  given  in 
pill,  in  emulsion  of  cod-liver  oil,  or  with  wine. 

j^L  Creosoti,  TTlxv ; 
Olei  morrhu£e,  f^iij  ; 
Calcii  et  sodii  hyposphos. ,  jss  \ 
Olei  gaultherige,  TTLxx ; 
Acacise,  q.  s. 
Aquae,  q.  s.  ad  fivj. — M. 
Sig.-*A  tablespoonful  two  hours  after  meals. 

The  carbonate  of  guaiacol,  being  odorless  and  tasteless,  and 
less  irritating  than  creosote,  is  preferable  to  the  latter.  The 
daily  dose  is  15  to  60  grains. 

R   Strychnin,  sulph.,  gr.  ss ; 

Codein.,  gr.  v ; 

Guaiacol  carbonat.,  gr.  c. — M. 
Pone  in  capsulas  No.  xx. 
Sig. — One  every  three  hours. 

Creosote  is  often  valuable  in  inhalations. 

^L  Creosoti, 

Spt.  chloroformi, 
Alcoholis,  aa  f^ss. — M. 
Sig. — Ten  to  twenty  drops  in  the  inhaler  several  times  daily. 


222  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Symptomatie  Treatment.  Cough. — Syrups  should  be  avoided 
as  far  as  possible,  and  cough  alleviated  by  inhalations  of  wine 
of  ipecac,  creosote,  benzoin,  or  terebene. 

Tar,  terebene,  and  eucalyptus  may  be  employed  internally. 
Cough  associated  with  the  expectoration  of  much  ofiensive 
material  should  not  be  checked. 

A  cold  bed  often  leads  to  cough  and  a  w^akeful  night ;  in 
these  cases  the  bed  should  be  warmed  before  it  is  occupied. 
Hot  applications  to  the  chest  and  a  hot  drink  on  retiring 
sometimes  insure  rest. 

The  following  mixture  is  very  efficient  in  the  cough  of 

phthisis : — 

^   Codeina3  sulph.,  gr.  iv  ; 

Acid,  hydrocyanic,  dil. ,  Ulsxxij  ; 
Syr.  tolu.,  fsij.— M.     (Da  Costa.) 
Sig. — A  teaspoonful  three  or  four  times  daily. 

Sweating.— AiYO^yne  (gr.  -^^^),  picrotoxin  [gv.  i^-^\  gallic 
acid  (gr.  x),  camphoric  acid  (gr.  xx-xxx),  agaricin  (gr.  1-1). 

^  Atropin.  sulph.,  gr.  | ; 
Acid,  sulph.  aroraat.,  f^ij  ; 
AquEe  ros8e,  q.  s.  ad  f^j. — M. 
Sig. — Twenty  to  thirty  drops  at  hedtime,  and  repeated  if  neces- 
sary. 

Sponging  with  alum  and  whiskey  is  sometimes  very  efficacious. 

Hcemoptysis. — When  profuse,  ice  may  be  held  in  the  mouth 
and  swallowed  slowly.  The  fluid  extract  of  ergot  (gtt.  xx- 
xxx)  and  morphine  (g.  \)  should  be  given  hypodermically. 
The  internal  administration  of  gallic  acid  and  other  astrin- 
gents is  of  little  value.  The  application  of  a  temporary  liga- 
ture to  one  or  more  of  the  members  hinders  the  flow  of  blood 
in  the  veins,  and  may  materially  aid  in  checking  the  bleeding. 

When  the  hemorrhage  is  more  or  less  continuous,  but  not 
profuse,  the  fluid  extract  of  hamamelis  (5ij-3iij)  or  pills  of 
acetate  of  lead  and  opium  are  efficient  remedies. 

Diarrhoea. — Eest ;  liquid  diet ;  subnitrate  of  bismuth  in 
large  doses,  or  pills  of  nitrate  of  silver  and  opium. 

^  Bismuth,  subnit.,  3yj ; 

Salol,  gr.  xxiv ; 

Morphin.  sulph.,  gr.  j. — M. 
Ft.  in  chart.  Ko.  xii. 
Sig. — One  powder  every  three  hours. 


PLEURISY. 


223 


Pyrexia. — Rest  is  imperative.  Quinine  or  antipyrin,  or 
sponging  with  alcohol  and  cool  water,  may  prove  useful. 
Guaiacol  (10-20  drops)  applied  externally  has  been  advo- 
cated, but  its  use  is  often  followed  by  chills,  sweating,  and 
even  collapse. 

Pain. — The  pleuritic  pains  may  be  relieved  by  opium  and 
the  application  of  adhesive  strips,  dry  cups,  or  iodine. 

PLEURISY. 

(Pleuritis.) 

Depinitiojst. — Inflammation  of  the  pleura. 

Varieties. — According  to  cause,  it  may  be  divided  into 
primary  or  secondary ;  according  to  extent,  into  unilateral, 
bilateral,  or  local;  according  to  time,  into  acute  or  chronic; 
and  according  to  the  exudation,  into  sero-fibrinous,  fibrinous, 
or  purulent. 

Etiology.' — Pleurisy  may  be :  (1)  Idiopathic,  arising  from 
exposure  to  cold  and  wet.  (2)  Traumatic.  (3)  Secondary  to 
inflammatory  diseases  of  adjacent  viscera,  as  pneumonia  and 
phthisis.  (4)  Secondary  to  some  general  morbid  process,  as 
rheumatism,  Bright's  disease,  tuberculosis,  and  the  infectious 
fevers.     (5)  Tuberculous.     (6)  Cancerous  (rare). 

Pathology. — In  the  early  stage  the  membrane  is  red, 
sticky,  lustreless,  and  covered  with  a  thin  film  of  lymph  ;  if 
the  process  now  ceases,  the  condition  is  termed  dry  pleurisy. 
If,  however,  the  inflammation  continues,  an  exudate  is  formed 
which  may  be:  (1)  Sero-fibrinous,  (2)  fibrinous,  or  (3)  puru- 
lent (empyema).  In  the  sero-jibrinoiis  form  there  is  little 
lymph,  the  exudate  being  mainly  composed  of  straw-colored 
serum  (a  few  ounces  to  several  pints)  which  in  favorable 
cases  is  gradually  absorbed.  In  large  effusions  the  adjacent 
organs  are  displaced  and  the  lungs  are  compressed.  In  the 
fibrinous  form  serum  is  scant  and  the  membrane  is  cov- 
ered with  a  butter-like  exudate  which  subsequently  organizes 
and  unites  more  or  less  closely  the  pleural  surfaces,  causing 
adhesive  pleurisy.  A  liquid  effusion,  which  is  circumscribed 
and  confined  to  pockets  formed  of  adhesions,  is  termed^tccM- 
lated  pleurisy.  *" 


224  DISEASES  OF  THE  RESPIRATOEY  SYSTEM. 

In  the  j^urulent  form  the  sac  is  more  or  less  filled  with 
greeuish-yellow  pus.  Purulent  pleurisy,  or  empyema,  is  com- 
mon in  children ;  it  frequently  follows  the  infectious  fevers  ; 
it  is  often  secondary  to  a  sero-fibrinous  pleurisy  ;  it  results 
from  the  rupture  of  purulent  accumulations  into  the  pleura, 
as  by  a  tuberculous  cavity ;  and  finally,  it  may  be  due  to 
traumatism,  as  a  penetrating  wound  or  fracture  of  the  ribs. 

A  purulent  effusion  left  to  itself  may  kill  by  sepsis,  may 
become  inspissated  and  encysted  (rare),  or  may  perforate  into 
the  bronchi,  into  neighboring  organs,  or  externally. 

HemorrhaglG  Pleurisy. — A  bloody  effusion  is  observed  in 
tuberculous  and  cancerous  pleurisies  and  in  pleurisy  which  is 
associated  with  scurvy,  grave  anaemia,  and  other  cachectic 
states. 

An  effusion  of  any  kind  remaining  unabsorbed  constitutes  a 
chronic  pleurisy. 

Symptoms.  A(Mte  Pleurisy. — Chilliness  ;  a  stabbing  pain 
or  stitch  in  the  affected  side,  intensified  by  deep  breathing 
and  by  cough;  moderate  fever  (101°-103°);  cough  short, 
dry,  and  partially  suppressed ;  the  face  is  generally  pale  and 
anxious ;  and  the  patient  usually  lies  on  the  affected  side. 

When  the  effusion  forms,  the  inflamed  surfaces  separate,  so 
that  the  pain  becomes  less ;  but  dyspnoea  rapidly  develops,  and 
the  respirations  are  of  a  short,  jerky  character. 

Physical  Signs.  First  Stage.  —  Less  expansion  on  the 
affected  side  on  account  of  the  pain ;  occasionally  a  friction- 
fremitus  on  palpation,  and  a  harsh  to-and-fro  friction-rub  on 
auscultation. 

Stage  of  Effusion.  Inspection. — Immobility  and  bulging  of 
the  intercostal  spaces  on  the  affected  side.  The  apex-beat  is 
displaced  upwards,  and  to  the  left  or  right  according  to  the 
pleura  affected. 

Palpation. — Immobility  and  diminished  vocal  fremitus. 

Percussion. — Dulness  gradually  rising  as  the  fluid  increases. 
The  upper  line  of  dulness  is  not  horizontal,  but  is  curved  and 
rises  higher  posteriorly.  In  moderate  effusions  the  level  of 
dulness  often  changes  with  the  position  of  the  patient.  Above 
the  effusion  percussion  gives  a  tympanitic  note  which  has  been 
termed  Skoda's  resonance. 


PLEURISY.  225 

Auseultation. — ^The  respiratory  sounds  are  weak  and  dis- 
tant ;  they  may  have  a  tubular  or  bronchial  quality.  The 
vocal  resonance  is  usually  diminished  or  absent,  but  occa- 
sionally bronchophony,  or  its  modification  segophony  (a  bleating 
sound),  is  heard  over  moderate  elFnsions. 

Ilensuration. — The  affected  side  is  sometimes  an  inch  or 
more  larger  than  the  sound  one. 

After  absorption  of  the  effusion  the  friction-sound  returns. 

Diagnosis.  Pneumonia. — The  severe  chill,  rusty  expec- 
toration, high  fever,  marked  dyspnoea,  the  fine  crepitant  rales 
which  are  heard  ouly  on  inspiration,  dnlness  not  changing  with 
the  patient's  posture,  increased  vocal  fremitus,  increased  vocal 
resonance,  loud  bronchial  breathing,  and  the  absence  of  bulg- 
ing and  of  a  displaced  apex-beat,  will  serve  to  distinguish  it 
from  pleurisy. 

Pleurodynia,  or  Rheumatism  of  the  Intercostal  Muscles, — No 
fever,  much  diffuse  tenderness,  no  friction-sounds,  and  no 
effusion. 

Purulent  pleurisy  is  recognized  by  hectic  sym ptosis — high 
and  irregular  fever,  sweats,  chills,  and  anaemia ;  by  the  results 
of  aspiration  ;  and  sometimes  by  "  pitting"  from  oedema  of  the 
surface.  — — 

Fibrinous  Pleurisy. — Pain  is  severe  and  continuous,  the 
dulness  is  immobile,  aspiration  gives  negative  results,  and  later 

there  is  much  rpt,rnr.tini^  nf  thp  i^Wf^n^(^c^  side. 

Tuberculous  Pleurisy. — Tuberculosis  is  the  most  common 
cause  of  pleurisy  which  is  apparently  primary.  It  may  be 
primary  or  secondary  to  pulmonary  phthisis.  It  usually  pre- 
sents the  same  symptoms  as  ordinary  sero-fibrinous  pleurisy, 
but  it  often  develops  insidiously,  is  frequently  bilateral,  and 
the  effusion  is  apt  to  be  bloody.  These  facts,  together  with 
the  history,  will  usually  indicate  the  diagnosis. 

Diaphragmatic  pleurisy,  or  inflammation  of  the  diaphrag- 
matic pleura,  may  present  the  following  symptoms :  Intense 
]min  under  the  margin  of  the  ribs,  with  teuderness  on  pressure ; 
thoracic  breathing ;  tenderness  over  the  phrenic  nerve,  which 
is  accessible  between  the  two  roots  of  the  sterno-cleido-mastoid 
at  the  base  of  the  neck ;  hiccough ;  and  extreme  dyspnoea. 
The  physical  signs  are  not  marked. 
15 


226  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

Prognosis. — This  depends  largely  on  the  character  and 
the  amount  of  effusion.  In  primary  sero-fibrinous  pleurisy, 
the  prognosis  is  usually  good,  but  that  pleurisies,  which  are 
apparently  primary,  are  often  tuberculous,  should  always  be 
borne  in  mind.  In  purulent  pleurisy,  the  prognosis  is  grave, 
though  recovery  frequently  occurs. 

In  the  fibrinous  form,  the  prognosis  is  good,  but  if  there 
has  been  much  exudate,  subsequent  retraction  and  more  or 
less  impairment  of  the  affected  side  are  sure  to  follow. 

Treatment. — Absolute  rest.  Light  diet.  If  the  temper- 
ature is  high  and  the  pulse  rapid,  aconite  may  be  administered 
in  small  doses.  Quinine  (gr.  v  thrice  daily)  will  exert  a  favor- 
able influence.  Pain  may  be  so  severe  as  to  require  morphia 
hypodermically. 

Local  Applications. — When  the  pain  is  severe,  leeches  or 
wet-cups,  followed  by  strapjiing  of  the  chest,  will  give  -great 
relief.  In  other  cases,  mustard  plasters,  hot  fomentations,  or 
iodine  may  be  applied. 

Serous  Effusion. — Apply,  frequently,  small  blisters.  Iodide 
of  potassium  (gr.  v  thrice  daily)  may  be  employed  for  its  ab- 
sorbent effect. 

Encourage  diuresis  with  digitalis,  caffeine,  or  acetate  of 
potassium : — 

^  Potass,  acetat.,  ^ss  ; 

Infus.  digitalis,  f  §iij. — M. 
Sig. — Two  teaspooufuls  every  three  or  four  hours. 

Encourage  catharsis  with  compound  jalap  powder  (gr.  xx- 
xxx)  or  Epsom  salts. 

T^  Magnesii  sulphat.,  5iv-^vj. 
Div.  in  chart.  No.  viii. 

Sig. — One  powder  in  two  tablespoonfuls  of  water  before  food,  and 
no  fluids  for  some  time  afterwards. 

The  effusion  will  require  aspiration  under  the  following 
conditions  :  (1)  When  it  excites  much  dyspnoea  ;  (2)  when  it 
is  very  large,  beyond  the  third  or  fourth  rib  ;  (3)  when  it  is 
purulent ;  (4)  when  it  remains  unabsorbed  after  three  or  four 
weeks  of  careful  treatment ;  (5)  when  it  is  bilateral,  and  the 
total  amount  is  sufficient  to  fill  one  cavity. 


HYDEOTHOEAX — PNEUMOTHORAX.         227 

The  Operation. — Anaesthetize  a  point  in  the  seventh  inter- 
space near  the  posterior  axillary  line  and  introdnce  the  needle 
with  a  quick  stroke  along  the  upper  border  of  the  rib.  The 
effusion  should  be  drawn  off  slowly,  and  one  or  two  pints  re- 
moved according  to  the  amount  of  the  exudate. 

Coughing  during  the  operation  is  an  indication  for  the  with- 
drawal of  the  needle. 


HYDROTHORAX. 

Definition, — ^Thoracic  dropsy. 

Etiology. — It  is  always  secondary,  and  may  result  from 
one  of  the  causes  of  general  dropsy,  namely  :  Bright's  disease, 
heart  disease,  emphysema  or  anaemia,  or  from  the  pressure  of 
a  tumor  or  aneurism  upon  the  thoracic  veins. 

Symptoms. — Dyspnoea,  cyanosis,  and  the  physical  signs  of 
a  pleural  effusion. 

Diagnosis. — The  history  of  the  primary  disease,  the  fact 
that  the  effusion  is  bilateral,  the  absence  of  pain,  and  the  pres- 
ence of  a  fluid  which  is  only  slightly  albuminous,  and  which 
shows  little  or  no  tendency  to  spontaneous  coagulation,  will 
serve  to  distinguish  it  from  'pleurisy. 

Treatment. — Remedies  should  be  directed  to  the  original 
disease.     When  there  is  much  dyspno3a,  aspirate. 

PNEUMOTHORAX. 

Definition. — Air  in  the  pleural  sac. 

Etiology. — It  may  result  from  :  (1)  The  rupture  of  the 
hing  in  health  from  a  violent  strain,  or  rupture  in  tuberculosis, 
abscess,  emphysema,  or  gangrene.  (2)  Traumatism,  as  a  pen- 
etrating wound  or  a  fracture  of  the  ribs.  (3)  The  rupture  of 
an  empyema  into  the  lung. 

Pathology. — The  adjacent  viscera  are  displaced,  and  the 
lung  is  compressed.  Even  when  air  alone  has  escaped  into 
the  pleural  sac,  an  effusion  soon  develops,  so  that  in  all  cases 
the  condition  becomes  a  pneumo-hydrothorax  or  -pyothorax. 


228  DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

Symptoms. — The  onset  is  marked  by  a  sharp  pain,  extreme 
dyspnoea,  cyanosis,  and  symptoms  of  incipient  collapse,  namely, 
a  fall  of  temperature,  a  weak  rapid  pulse,  cold  extremities,  and 
pinched  features. 

Physical  Signs.  Inspection. — Immobility,  and  bulging 
of  the  intercostal  spaces.     The  apex -beat  is  usually  displaced. 

Palpation. — Diminished  vocal  fremitus. 

Percussion. — A  tympanitic  note,  varying  in  pitch  with  the 
intrathoracic  tension. 

Eifusiou  sinks  to  the  base  and  yields  dulness,  the  outline  of 
which  changes  with  the  position  of  the  patient. 

Auscultation. — The  respiratory  murmur  and  vocal  resonance 
are  usually  absent,  but  when  the  opening  in  the  lung  remains 
patulous,  amphoric  breathing  may  be  detected.  When  a  silver 
coin  is  placed  on  the  affected  side  and  is  struck  with  another, 
the  auscultator  detects  a  clear  metallic  sound  (bell-tympauy). 
When  fluid  is  present,  shaking  the  patient  excites  a  splashing 
sound  (Hippocratic  succussion). 

Diagnosis.  A  large  Phthisical  Cavity. — This  is  usually 
located  near  the  apex  instead  of  the  base ;  the  surface  is 
sunken,  not  prominent ;  the  heart  is  not  displaced ;  succus- 
siou-splash  and  bell-tympany  are  usually  absent. 

Dilated  Stomach. — This  may  give  a  tympanitic  note  over 
the  left  pulmonary  base,  and  may  simulate  a  pneumothorax ; 
but  the  tympanitic  note  is  continued  down  into  the  abdomen, 
and  the  swallowing  of  liquid  is  distinctly  audible  over  the, 
base  of  the  chest. 

Prognosis. — It  is  usually  unfavorable,  and  often  termi- 
nates fatally  in  a  few  hours  or  days.  Recovery  is  possible, 
especially  in  traumatic  cases.  It  often  excites  a  pleural  effu- 
sion and  runs  a  chronic  course. 

Treatment. — At  the  onset  administer  stimulants,  and  apply 
straps  to  the  chest.  The  pain  and  distress  must  be  relieved  by 
morphine.  When  effusion  forms  it  should  be  treated,  accord- 
ing to  its  character,  as  a  serous  or  a  purulent  pleurisy. 


HEMOTHORAX.  229 

HEMOTHORAX. 

(Hsematothorax. ) 

Definition. — The  effusion  of  blood  into  the  pleural  sac. 

Etiology. — Traumatism,  rupture  of  an  aneurism,  or  the 
erosion  of  bloodvessels  by  cavities  or  caries  of  the  ribs. 

Symptoms. — Same  as  hydrothorax. 

Treatment. — When  there  is  great  dyspncea  the  blood 
should  be  removed  by  aspiration  or  incision. 

PYOTHORAX. 

(Empyema.) 

Definition. — An  effusion  of  pus  into  the  pleural  sac. 

Etiology. —  (1)  The  effusion  may  be  primarily  purulent, 
the  inflammation  having  been  excited  by  pyogenic  microor- 
ganisms. (2)  A  sero-fibrinous  pleurisy,  through  subsequent 
infection,  may  be  converted  into  an  empyema.  The  predis- 
posing causes  are  much  the  same  as  those  of  sero-fibrinous 
pleurisy.  Traumatism  or  the  rupture  of  a  purulent  accumu- 
lation into  the  pleural  sac  is  an  occasional  cause.  It  frequently 
follows  pneumonia,  particularly  in  children,  in  whom  the  most 
common  form  of  pleurisy  is  empyema.  It  is  often  secondary 
to  tuberculosis  or  one  of  the  infectious  fevers. 

Streptococci,  pneumococci,  tubercle  bacilli,  Eberth's  bacilli, 
and  staphylococci  are  capable  of  exciting  empyema. 

Symptoms. — The  physical  signs  and  symptoms  are  similar 
to  those  observed  in  sero-fibrinous  pleurisy.  Pus  is  indicated 
by  hectic  phenomena — high  and  irregular  fever,  sweats,  chills, 
and  anaemia;  by  the  results  of  aspiration;  and  sometimes  by 
oedema  of  the  chest-walls.  In  pulsating  pleurisy  the  effusion 
is  almost  always  purulent. 

Prognosis. — Grave,  though  recovery  frequently  occurs. 
The  most  favorable  cases  are  those  following  pneumonia. 

Treatment. — Free  incision  and  thorough  drainage.  Irri- 
gation is  unnecessary  unless  the  fluid  is  putrid.  In  long-stand- 
ing cases  the  excision  of  several  ribs  (Estlander's  operation) 
facilitates  retraction  and  the  obliteration  of  the  pleural  sac, 
which  is  essential  to  a  cure. 


ACUTE  INFECTIOUS  DISEASES. 


FEVER. 


Fever  is  an  abnormal  condition  characterized  by  elevated 
temperature,  quickened  respiration  and  circulation,  faulty  se- 
cretions, and  increased  tissue- waste  ;  and  dependent  upon  a 
perversion  of  the  physiological  processes  whereby  the  gene- 
ration and  loss  of  heat  are  so  balanced  as  to  maintain  a  uni- 
form normal  temperature. 

The  Detection  of  Fever. — There  is  only  one  sure  way  of 
detecting  fever,  aud  that  is  by  means  of  the  clinical  ther- 
mometer. The  instrument  may  be  placed  in  the  axilla, 
mouth,  rectum,  or  vagina. 

When  the  axilla  is  selected  the  following  precautions  must 
be  observed  :  Wipe  off  the  perspiration  and  dry  the  skin  ;  in- 
sert the  bulb  of  the  instrument  deep  in  the  armpit,  and  see 
that  the  arm  is  kept  close  to  the  side.  The  thermometer 
should  be  kept  in  position  until  the  mercury  maintains  the 
same  level  for  two  minutes ;  this  will  usually  require  in  all 
about  six  or  seven  minutes. 

When  the  mouth  is  selected  the  bulb  should  be  placed 
under  the  tongue  and  the  lips  kept  closed.  Hot  and  cold 
drinks  recently  taken  mar  the  results.  For  obvious  reasons 
the  mouth  should  not  be  used  in  delirious  patients. 
r  The  rectum  may  be  selected  in  children.  The  rectal  tem- 
perature is  about  a  degree  higher  than  that  of  the  axilla. 

Febrile  Stages. — The  course  of  all  fevers  is  marked  by  three 
/■stages:   (1)  Invasion;  (2)  fastigium,  or  stadium;  (3)  defer- 
vescence, or  decline. 

Invasion. — During  this  period  the  temperature  gradually 
rises  until  it  reaches  its  maximum. 
(230) 


FEVER.  231 

Fastigium. — In  this  period,  though  there  may  be  marked 
variations,  the  temperature  shows  a  tendency  to  touch  again 
and  again  its  highest  point. 

Defervescence. — In  this  period  the  temperature  gradually 
falls  until  it  reaches  the  norm. 

Terminations  of  Fever.  —  Fever  terminates  by  lysis  or 
crisis. 

Lysis. — The  temperature  falls  slowly  by  slight  gradations 
until  it  reaches  the  norm. 

Q^sis. — The  temperature  falls  suddenly,  often  four  or  five 
degrees  in  twelve  or  twenty-four  hours. 

The  Degree  of  Pyrexia. — The  following  is  Wunderlich's 
classification  of  febrile  temperatures  : — 

1.  Subfebrile,  temperature  99.5°-100.4°. 

2.  Slightly  febrile,  temperature  100.4°-101.3°. 

3.  Moderately  febrile,  temperature  101. 3°-l 03.1°. 

4.  Decidedly  febrile,  temperature  103.1°-104°. 

5.  Highly  febrile,  temperature  above  103.1°  in  the  morning 

and  above  104.9°  in  the  evening. 
CQ.  Hyperpyretic,  temperature  above  106°. 

Febrile  Remissions. — All  fevers  show  a  diurnal  variation. 
The  maximum  is  usually  reached  at  about  6  P.M.  and  the 
minimum  at  about  6  A.M.  Sometimes  these  extremes  are  re- 
versed and  the  maximum  is  in  the  morning  and  the  minimum 
in  the  evening.     The  daily  difference  amounts  to  about  1°. 

Types  of  Fever. — According  to  the  degree  of  the  diurnal 
variation  three  types  are  recognized  : — 

1.  Continued  Fever. — The  diurnal  variation  is  slight,  1°-1. 5°. 
Typhus  fever,  pneumonia,  and  scarlet  fever  are  examples  of 
continued  fevers. 

2.  Remittent  Fever. — The  diurnal  variation  is  marked,  but 
the  minimum  temperature  is  still  above  the  norm.  Typhoid 
fever,  remittent  fever,  and  hectic  fever  are  examples  of  this 
type. 

3.  Intermittent  Fever. — The  diurnal  variation  is  marked,  and 
the  minimum  is  normal  or  subnormal.  The  following  fevers 
intermit : — 


232  ACUTE  INFECTIOUS   DISEASES. 

'  1.  Intermittent  fever  (malaria). 

2.  Relapsing  fever. 

3.  Hectic  fever  (oflen  intermits,  though  generally  remits). 

4.  Charcot's  intermittent  (the  peculiar  fever  associated  with 

the  impaction  of  gall-stones). 

Causes  of  Fever.  —  (])  Local  inflammations  excited  by 
external  causes,  or  the  products  of  faulty  metabolism 
(gout,  rheumatism).  (2)  The  presence  in  the  body  of  micro- 
organisms, or  of  toxines  produced  by  them,  as  in  typhoid 
,  fever,  pyaemia,  scarlet  fever,  etc.  (3)  Paralysis  of  the  heat- 
centre,  as  in  thermic  fever. 

Symptoms  of  Fever. — Rise  of  temperature ;  rapid  pulse ; 
rapid  respirations ;  coated  tongue  ;  anorexia ;  constipation. 
The  urine  is  scanty,  high-colored,  throws  down  a  heavy  sedi- 
ment, and  may  contain  a  trace  of  albumin.  The  gastric  juice 
is  deficient  in  acid.  If  the  fever  is  long-continued,  the  body 
wastes. 

The  Pulse-temperature  ratio : — 

A  temperature  of    98.4°  corresponds  to  a  pulse  of  70 

u               a     100°              "             "         "     ^  80-  90 

«               "     102°              "             "         "  100-110 

"               "     104°              "             "         "  120-130 

Effects  of  Fever  on  the  Tissues. — High  and  long-continued 
fever  produces  fatty  and  parenchymatous  degeneration  of  the 
tissues. 

Treatment  of  Fever. — Absolute  rest ;  a  cool,  well-ventilated 
room  ;  liquid  or  semi-liquid  diet.  Slight  fever  will  require  no 
special  remedies,  but  the  patient  may  be  made  more  comfort- 
able by  sponging  with  cool  water,  or  water  and  alcohol ;  and 
by  the  use  of  such  drugs  as  sweet  spirits  of  nitre,  acetate  of 
ammonium,  or  neutral  mixture. 

High  fever  is  best  controlled  by  the  external  application 
of  cold;  this  method  includes  sponging  with  cold  Mater,  the 
cold  pack,  and  the  cold  bath. 

The  Cold  Pad:,. — A  rubber  sheet  is  slij)ped  under  the  patient, 
and  the  body  is  enveloped  in  a  sheet  wrung  out  in  cold  w^ater, 


FEVER.  233 

which  is  allowed  to  remain  until  the  temperature  falls  one  or 
two  degrees. 

The  Cold  Bath. — There  are  two  methods  of  administering 
the  cold  bath.  The  first  is  to  place  the  patient  at  once  into 
water  at  70° ;  the  other  is  to  place  him  into  water  at  90°  or 
80°,  and  then  gradually  cool  it  down  to  75°  or  70°.  While  in 
the  water  he  should  be  subjected  to  gentle  friction  or  massage. 
He  should  remain  in  the  bath  for  fifteen  or  twenty  minutes, 
after  which  he  should  be  placed  in  a  dry  sheet  and  covered 
with  a  light  blanket.  AYhen  the  body  is  dry  the  damp  sheet 
should  be  removed.  A  stimulant  is  sometimes  required  during 
or  after  the  bath. 

Drugs  may  be  employed  to  lower  temperature,  but  the  bath 
is  preferable  when  it  is  feasible.  Quinine,  antipyrin,  phe- 
nacetiu,  and  acetauilid  are  the  antipyretics  most  commonly 
employed. 

Period  of  Incubation. — The  period  elapsing  between  the  en- 
trance of  the  poison  and  the  development  of  symptoms. 

It  varies  considerably  in  the  same  disease,  being  more  or  less 
influeuced  by  the  susceptibility  of  the  patient  and  the  virulence 
of  the  contagion.  The  average  period  of  incubation  in  the  in- 
fectious fevers  is  as  follows  : — 

Typhoid  fever:  two  to  three  weeks. 

Typhus  fever:  a  few  hours  to  two  weeks. 

Measles:  two  weeks. 

Rotheln  or  rubeUa:  ten  to  twelve  days. 

Scarlatina :  a  few  hours  to  a  week. 

Smallpox :  one  to  two  weeks. 

Erysipelas :  three  to  seven  days. 

Diphtheria :  two  to  ten  days. 

Varicella :  ten  to  fifteen  days. 

Tetanus :  a  few  days  to  two  weeks. 

Mumps:  two  to  three  weeks. 

Yellow  fever :  from  a  few  hours  to  a  week. 

The  date  at  which  rashes  appear  in  the  various  diseases: — 

Typhoid  fever:  seventh  to  the  ninth  day. 
Typhus  fever :  fourth  or  fifth  day. 


234  ACUTE  INFECTIOUS  DISEASES. 

Smallpox :  third  or  fourth  day. 
Measles :  third  or  fourth  day. 
Scarlatina:  first  or  second  day. 
Rotheln  or  rubella:  first  or  second  day. 
Varicella :  first  day. 

Protection  from  Future  Attacks. — Few  diseases  give  abso- 
lute immunity  from  future  attacks,  but  the  following  are  fairly 
protective : — 

Typhoid  fever :  relapses  are  common,  and  second  attacks  some- 
times occur. 

Typhus  fever  :  second  attacks  very  rare. 

Measles :  second  attacks  uncommon  ;  what  is  supposed  to  be  a 
second  attack  is  usually  rotheln. 

Rotheln :  second  attacks  uncommon. 

Scarlatina :  second  attacks  rare. 

Smallpox :  second  attacks  occasionally  occur. 

Mumps :  second  attacks  rare. 

Yellow  fever:  second  attacks  rare. 

The  following  do  not  confer  immunity  : — 

Erysipelas.  Malaria. 

Relapsing  fever.  Influenza. 

Diphtheria.  Croupous  pneumonia. 

Periodic  Remission  or  Intermissions  in  the  Fever. — Such 
remissions  or  intermissions  occur  in  the  following  fevers : — 

Malarial  fever:  every  day,  every  third  day,  or  every  fourth 

day,  according  to  the  type. 
Relapsing  fever  :  intermissions  occur  at  intervals  of  five  or  six 

days,  and  last  five  or  six  days. 
Smallpox :  remission  occurs  on  the  third  day. 
Measles:  a  distinct  remission  often  occurs  on  the  second  or 

third  day. 
Yellow  fever :  a  marked  remission  on  the  second  or  third  day. 
Dengue:    a  marked   remission   on   the  third  or  fourth  day, 

which  lasts  two  or  three  days,  and  is   repeated  about  the 

ninth  or  tenth  day. 


SUBNORMAL  TEMPERATURE.  235 

The  Infectious  Fevers  which  are  usually  Associated 
with  Jaundice: — 

Yellow  fever. 

Eelapsing  fever. 

Acute  yellow  atrophy  of  the  liver. 

Bilious  remittent  fever. 

Termination  by  Crisis. — The  following  infectious  fevers  are 
apt  to  end  by  crisis  : — 

Typhus  fever.  Measles. 

Pneumonia.  Relapsing  fever. 

Influenza.  Erysipelas. 

SUBNORMAL.  TEMPERATURE. 

Temperatures  below  97.5°  may  be  considered  subnormal. 
They  are  observed  in  the  following  conditions  : — 

1.  During  convalescence  from  certain  febrile  diseases;  after 
pneumonia  and  typhoid  fever  the  temperature  may  remain 
subnormal  for  several  days. 

2.  In  collapse.  This  may  result  from  shock  ;  from  hemor- 
rhage ;  from  the  action  of  some  toxic  agent ;  froDi  simple  heart- 
failure  in  the  course  of  disease ;  or  from  the  rupture  of  a  viscus, 
as  the  bowel  in  typhoid,  the  lung  in  phthisis,  or  the  stomach  in 
perforating  ulcer. 

3.  In  cholera.  In  this  disease  the  temperature  may  be  very 
low  (90°-85°)  for  several  days. 

4.  In  certain  chronic  diseases,  especially  diabetes,  cancer, 
chronic  cardiac,  cerebral,  and  spinal  diseases. 


236  ACUTE  INFECTIOUS   DISEASES. 

SIMPLE  CONTINUED  FEVER. 

(Febripula,  Ephemeral  Fever.) 

Definition. — An  acute  febrile  disease,  of  short  duration, 
and  not  excited  by  a  special  poison. 

Etiology. — It  is  generally  met  with  in  young  and  sensi- 
tive individuals.  Exposure  to  the  sun,  prolonged  physical  or 
emotional  excitement,  and  errors  in  diet  seem  to  excite  it. 

Symptoms. — The  disease  usually  begins  abruptly  with 
chilliness,  headache,  malaise,  and  fever  which  soon  attains  a 
maximum  of  102°  or  103°.  The  face  is  flushed  ;  the  pulse  is 
full  and  rapid  ;  the  urine  is  scanty  and  high  colored ;  the 
tongue  is  coated  ;  the  appetite  is  lost ;  and  the  bowels  are  con- 
stipated. There  is  no  characteristic  eruption,  but  herpes  is 
frequently  observed  on  the  lips. 

The  disease  lasts  from  a  few  days  to  two  weeks,  and  may 
end  by  crisis  or  lysis. 

Diagnosis. — Care  must  be  taken  to  exclude  local  injBam- 
mations,  such  as  gastritis,  tonsillitis,  and  pneumonia. 

Typhoid  Fever. — At  first  the  diagnosis  may  be  impossible, 
but  the  absence  of  diarrhoea,  tympanites,  abdominal  tender- 
ness, splenic  enlargement,  and  eruption  will  soon  make  the 
diagnosis  apparent. 

Remittent  Fever, — The  history,  locality,  splenic  enlargement, 
and  hsematozoa  in  the  blood  will  serve  to  distinguish  this  dis- 
ease from  simple  continued  fever. 

Prognosis. — Favorable. 

Treatment. — Absolute  rest  in  bed.  A  liquid  diet.  Re- 
peated small  doses  of  calomel  may  be  employed  to  relieve  the 
constipation. 

The  fever  may  be  controlled  by  sponging  with  water  and 
alcohol  or  by  the  use  of  some  mild  refrigerant  mixture  like  the 
following : — 

Tinct.  aconit.  rad.,  gtt.  iij  ; 
Spt.  fether.  nitrosi,  fsss  ; 
Liquor,  amnion,  acetat.,  q.  s.  ad  f5iij. — M. 
Sig. — A  dessertspoonful  every  two  hours  to  a  child  of  four  years. 


TYPHOID   FEVEB.  237 

TYPHOID  FEVER. 

(Enteric  Fever,  Typhus  Abdominalis.) 

Definition. — An  acute  infectious  disease,  excited  by  a 
special  bacillus,  characterized  anatomically  by  definite  lesions 
in  Peyer's  patches,  mesenteric  glands,  and  spleen ;  and  mani- 
fested clinically  by  fever,  headache,  stupor,  abdominal  disten- 
tion and  tenderness,  diarrhoea,  enlargement  of  the  spleen,  and 
a  rose-colored  abdominal  rash. 

Etiology. — Predisposing  causes  :  Autumn  season,  early 
adult  life,  and  a  personal  susceptibility. 

Exciting  cause  :  The  bacillus  of  Eberth.  The  intestinal 
discharges  are  the  source  of  the  contagion,  and  drinking-water 
contaminated  by  them  becomes  the  chief  medium  of  trans- 
mission. 

Pathology. — The  characteristic  lesions  are  found  in  the 
abdominal  lymphatics,  namely,  in  Peyer's  patches,  solitary 
glands,  and  mesenteric  glands.  The  changes  in  Peyer's  glands 
are  best  studied  in  the  lower  part  of  the  ileum,  which  should 
be  opened  on  the  side  of  the  mesenteric  attachment. 

In  the  first  few  days  the  glands  are  swollen  and  hypersemic ; 
later  there  is  a  marked  cell-proliferation,  the  bloodvessels  are 
compressed,  and  the  glands  become  pale  and  prominent  (me- 
dullary infiltration).  If  the  disease  advances,  necrosis  sets  in 
about  the  second  week ;  the  glands  become  yellow  and  soft 
and  discharge  their  contents,  leaving  behind  irregular  oval 
ulcers  with  swollen  and  undermined  edges,  and  with  smooth 
bases  formed  by  the  submucous  coat,  muscular  coat,  or  perito- 
neum. In  the  fourth  week  cicatrization  begins,  and  the  gland 
is  ultimately  replaced  by  a  smooth  depressed  scar. 

In  addition  to  these  glandular  lesions,  the  mucous  membrane 
of  both  large  and  small  intestines  shows  catarrhal  changes. 

In  mild  cases  the  stage  of  ulceration  may  not  be  reached, 
the  proliferated  cells  being  removed  by  fatty  degeneration  and 
absorption  without  rupture  of  the  gland.  The  solitary  and 
mesenteric  glands  pass  through  similar  changes,  but  the  latter 
rarely  rupture.  Other  lesions  are  found  which  are  not  charac- 
teristic.    The  spleen  is  soft  and  swoUen,  and  occasionally  rup- 


238  ACUTE   INFECTIOUS   DISEASES. 

tures.  The  liver,  kidneys,  heart,  and  muscles  reveal  paren- 
chymatous degeneration.  The  respiratory  tract  is  commonly 
the  seat  of  catarrhal  inflammation. 

Period  of  Incubation. — Two  to  three  weeks. 

Fig.  17. 


Temperature  curve  in  typhoid  fever. 

Symptoms.  Prodromal  Symptoms. — Gradual  weakness, 
headache,  vague  pains,  nose-bleed,  and  often  slight  diarrhoea. 

The  Attach.  Fever. — The  temperature  rises  gradually,  reach- 
ing a  maximum  (104°-105°)  in  from  one  to  two  weeks ;  it 
remains  at  this  elevation  for  another  period  of  from  one  to 
two  weeks,  when  a  gradual  defervescence  begins  and  occupies 
a  third  period  lasting  from  one  to  two  weeks.  Throughout 
its  course  the  fever  is  characterized  by  marked  daily  remis- 
sions, the  evening  temperature  being  from  one  to  three  degrees 
^higher  than  the  morning. 

In  some  cases,  especially  in  the  young,  the  temperature  rises 
quite  abruptly.  Slight  diurnal  remissions  indicate  a  protracted 
case.  As  defervescence  advances,  the  temperature  becomes 
more  irregular ;  the  remissions  are  more  decided,  and  not  in- 
frequently the  higher  temperature  is  recorded  in  the  morning. 
An  abrupt  fall  of  several  degrees  should  suggest  intestinal 
hemorrhage  or  perforation. 

Bespiratory  8ym])toms. — ^Hurried  respirations,  slight  cou^h, 
and  bronchial  rales. 

Circulatory  System. — The  pulse  becomes  rapid,  weak,  and 
dicrotic.  The  rapidity  is  often  less  than  such  temperatures 
generally  produce.  The  heart-sounds  become  feeble.  The 
first  is  especially  weak  and  resembles  the  second. 


TYPHOID   FEVER.  239 

The  Face. — The  expression  is  dull  and  heavy,  the  cheeks  N 
are  somewhat  flushed^  the  conjunctivse  are  clear,  and  the  pupils 
dilated. 

The  tongue  is  tremulous ;  at  first  it  is  red  at  the  tip  and 
edges,  and  covered  posteriorly  with  a  whitish  fur.  In  severe 
cases  the  tongue  becomes  dry,  brown,  and  fissured,  and  sordes 
collect  on  the  teeth. 

The  Stomach. — Gastric  symptoms  are  not  common,  but  ob- 
stinate vomiting  sometimes  develops  and  becomes  a  serious 
complication. 

Intestinal  Symptoms. — The  belly  is  distended  with  gas.  Ten- 
derness is  frequently  noted  on  palpation ;  it  may  be  general,  or 
confined  to  the  right  iliac  fossa.  Gurgling  may  also  be  detected 
in  the  latter  region,  but  it  has  little  significance.  Diarrhoea  is 
generally  present,  though  it  is  not  a  constant  symptom.  The 
discharges  vary  in  number  from  three  to  six  or  more  a  day ; 
they  are  thin,  offensive,  and  of  a  yellowish  color  (likened  to 
pea-soup) ;  on  standing,  a  turbid  liquid  rises  to  the  top  and  a 
granular  sediment  falls  to  the  bottom. 

The  Eruption. — This  appears  from  the  seventh  to  the  ninth  . 
day,  and  is  most  abundant  on  the  abdomen,  though  it  is  not 
infrequently  observed  on  the  chest  and  back.  It  is  composed 
of  small,  slightly  elevated,  rose-colored  spots  which  disappear 
on  pressure.  It  comes  out  in  successive  crops  over  several  days. 
It  may  be  absent  particularly  in  the  old  and  very  young. 
Rarely,  in  malignant  cases,  is  the  eruption  petechial. 

Sudamina  are  also  noted,  and  result  from  free  perspiration.  _ 

Splenic  enlargement  is  rarely  absent.    The  organ  may  rupture. 

Nervous  Symptoms. — Headache,  slight  deafness,  stupor; 
muttering  delirium,  twitching  of  the  tendons  (subsultus  ten- 
dinum),  picking  at  the  bedclothes  or  imaginary  objects  (car- 
phologia),  and  coma  vigil  (the  eyes  are  open,  but  the  patient 
is  unconscious). 

The  urine  is  febrile  and  often  slightly  albuminous.  Reten- 
tion is  common. 

Convalescence  is  marked  by  ansemia,  falling  of  the  hair,  de- 
squamation of  the  cuticle,  and  often  mental  enfeeblement. 

Varieties.  Mild  Typhoid.— There  is  moderate  fever  with 
marked  remissions;   the  diarrhoea  is  slight;  nervous  symp- 


240  ACUTE  INFECTIOUS  DISEASES. 

toms  are  often  absent ;  the  rash  is  usually  present,  and  often 
abundant. 

Abortive  Typhoid. — There  is  an  abrupt  onset  with  severe 
symptoms,  but  convalescence  follows  in  a  few  days. 

Walking  Typhoid. — The  symptoms  are  mild,  and  often  dis- 
regarded by  the  patient,  who  refuses  to  go  to  bed ;  but  grave 
symptoms  may  develop  suddenly,  and  death  from  perforation 
is  not  uncommon. 

Typhoid  in  Children. — The  rash  is  often  absent ;  the  fever 
lises  abruptly  ;  cerebral  symptoms  are  marked. 

Complications. — ^Any  symptom  aggravated  constitutes  a 
complication ;  thus  high  fever,  excessive  diarrhoea,  and  tym- 
panites become  complications. 

Hemorrhage. — This  usually  occurs  during  the  third  week, 
and  is  indicated  by  a  sudden  fall  of  temperature,  followed  by 
dark  red  or  tarry  stools. 

Peritonitis. — This  may  result  from  perforation,  or  from  ex- 
tension by  contiguity.  The  former  is  the  most  common,  and 
is  recognized  by  a  sudden  pain,  a  fall  of  temperture,  disten- 
tion of  the  belly,  and  symptoms  of  peritonitis. 

Pneumonia  and  hypostatic  congestion  of  the  lungs  are  com- 
mon complications. 

Among  less  frequent  complications  or  sequelse  may  be  men- 
tioned :  Nephritis,  pyelitis,  tuberculosis,  temporary  insanity, 
parotitis,  and  phlegmasia  dolens. 

Eelapse  and  Kecrudescence. — Relapses  are  quite  com- 
mon ;  they  repeat  the  symptoms  of  the  original  attack,  but 
they  are  generally  milder  and  of  shorter  duration,  and  seldom 
prove  fatal. 

Recrudescence. — This  is  a  sudden  temporary  elevation  of 
temperature  occurring  during  convalescence,  and  is  not  asso- 
ciated with  a  return  of  the  other  symptoms.  It  is  usually  due 
to  constipation,  excitement,  or  irritating  food. 

Diagnosis. — Acute  miliary  tuberculosis  often  closely  resem- 
bles typhoid  fever.  In  tuberculosis  the  temperature  is  gen- 
erally more  irregular;  the  abdominal  symptoms  are  less 
marked ;  pulmonary  symptoms,  especially  dyspnoea,  are  more 
marked ;  the  rash  is  absent ;  tubercles  may  be  detected  on  the 


TYPHOID   FEVER.  241 

retina ;  and  symptoms  of  basilar  meningitis  may  be  present, 
such  as  irregular  pupils,  ptosis,  and  strabismus. 

Ulcerative  Endocarditis. — The  diagnosis  may  be  impossible, 
but  the  following  features  would  suggest  endocarditis :  The 
history  of  a  primary  disease  which  might  induce  ulcerative 
endocarditis ;  irregular  fever ;  intercurrent  rigors ;  prsecordial 
pain  and  endocardial  murmurs ;  and  the  absence  of  a  rose- 
colored  rash  and  of  marked  abdominal  symptoms. 

Enteritis. — The  absence  of  high  fever,  of  eruption,  of  splenic 
enlargement,  of  epistaxis,  of  bronchial  catarrh  will  serve  to 
distinguish  enteritis  from  typhoid  fever. 

Meningitis. — The  abrupt  onset,  the  early  development  of 
cerebral  symptoms,  the  irregular  fever,  and  the  absence  of  a 
rash  and  of  abdominal  symptoms  will  indicate  meningitis. 

PnoaNOSis. — The  prognosis  should  always  be  guarded.  No 
case  is  too  mild  to  prove  fatal,  and  no  case  is  too  severe  to 
recover.  The  mortality  varies  in  different  epidemics.  In 
private  practice  the  average  is  probably  between  five  and  ten 
per  cent.,  and  in  hospital  practice  it  is  somewhat  more. 

Continued  high  fever  with  slight  diurnal  remissions,  exces- 
sive diarrhoea,  severe  cerebral  symptoms,  and  repeated  hemor- 
rhages are  unfavorable  features. 

Treatment. — Absolute  rest  in  bed  and  the  enforced  use 
of  the  bed-pan.  The  stools  should  be  rendered  innocuous. 
This  may  be  done  by  dissolving  a  pound  of  chloride  of  lime 
in  four  gallons  of  water,  and  adding  a  quart  of  the  solution 
to  each  discharge,  and  allowing  it  to  remain  in  the  vessel  at 
least  an  hour  before  disposing  of  it.  Soiled  bedclothes 
should  be  thoroughly  boiled. 

The  diet  must  be  liquid,  and  preferably  milk.  From  two 
to  four  pints  should  be  given  in  the  twenty-four  hours,  and 
should  be  so  divided  that  the  patient  shall  receive  a  small 
amount  every  two  hours,  day  and  night.  When  it  causes 
eructations  or  flatulence,  or  is  discharged  undigested,  it  must 
be  mixed  with  lime-water,  or  be  predigested.  Koumiss  is 
often  acceptable.  Meat-broths  may  be  given  to  vary  the 
monotony  of  a  milk  diet.  Cool  water  or  ice  will  be  required 
to  allay  thirst,  and  even  if  the  latter  is  absent,  it  is  well  to 
give  one  or  the  other  at  regular  intervals.  When  the  first 
16 


242  ACUTE  INFECTIOUS   DISEASES. 

sound  of  the  heart  weakens  and  the  pulse  becomes  soft,  stimu- 
lants should  be  administered.  It  is  desirable  to  give  the 
alcohol  with  the  milk  so  as  to  stimulate  the  stomach  to  digest 
the  latter,  and  at  the  same  time  to  diminish  the  number  of 
administrations  of  food  and  medicine.  From  four  to  eight 
ounces  of  brandy  or  whiskey  may  be  required  in  the  twenty- 
four  hours,  the  amount  being  determined  by  the  general  eflFect. 
When  additional  stimulation  is  required  strychnine  is  a  valu- 
able adjunct. 

When  the  tongue  becomes  dry  and  brown,  the  belly  much 
distended,  and  low  nervous  symptoms  develop,  turpentine 
will  be  found  an  invaluable  stimulant.  Five  to  ten  minims 
may  be  given  in  capsule  or  emulsion  every  two  or  four  hours. 

Antiseptic  remedies  have  been  strongly  advocated,  but  their 
efficiency  has  not  been  clearly  demonstrated.  Thymol,  naphthol, 
carbolic  acid,  chlorine-water,  iodine,  and  calomel  are  the  anti- 
septics which  have  been  recommended. 

The  use  of  the  cold  bath  or  the  cold  pack  will  be  found  an 
excellent  method  of  controlling  fever  and  of  preventing  the 
development  of  severe  nervous  symptoms.  It  is  especially  val-\ 
uable  as  a  stimulant  to  the  nerve-centres,  and  may  be  employed 
whenever  the  temperature  exceeds  102|-°.  Hemorrhage  and 
perforation  contraindicate  its  use.     (See  page  233.) 

Fever. — When  circumstances  prevent  the  use  of  the  cold 
bath,  sponging  with  cool  water  and  the  administration  of  such 
antipyretics  as  quinine  (gr.  xx— xxx)  or  antipyrin  (gr.  v— x) 
may  be  substituted. 

Diarrhoea. — When  diarrhoea  exceeds  more  than  three  or 
four  stools  a  day,  it  is  well  to  check  it  by  an  opium  sup- 
pository, or  by  bismuth  or  nitrate  of  silver  by  the  mouth. 

^  Pulv.  opii,  gr.  iij  ; 

01.  theobrom.,  q.  s. — M. 
Ft.  in  suppos.  No.  vi. 
Sig. — One,  two  or  three  times  daily. 

Or— 

^  Morpli,  sulph. ,  gr.  j  ; 

Creosot.,  gtt.  vj  ; 

Bismuth,  subnit.,  3iij. — M. 
Et.  in  chart,  l^o.  xii. 
Sig. — One  every  two  or  three  hours. 


TYPHUS  FEVER.  243 

Or— 


^  Argenti  nit. ,  gr.  v  ; 
Ext.  opii,  gr.  iv,— M. 
Ft.  in  pil.  No.  xx. 
Sig. — One  every  three  hours. 


Constipcdion. — This  may  be  relieved  by  an  enema  of  soap 
and  water,  or  by  broken  doses  of  calomel. 

Tympanites. — Turpentine  stupes.  Turpentine  or  thymol  in- 
ternally.    In  grave  cases,  rectal  intubation. 

Hemon^hage. — An  ice-bag  to  the  right  iliac  fossa.  Morphine 
(gr.  J)  with  ergotine  (gr.  v-x)  hypodermically.  Turpentine 
or  gallic  acid  may  be  administered  by  the  mouth. 

Perforative  Peritonitis. — This  is  almost  invariably  fatal. 
Opium  should  be  administered  freely.  Laparotomy  is  rarely 
warrantable 

Heart-failure. — When  alcohol  is  being  pushed  and  the 
symptoms  of  heart-weakness  still  persist,  such  remedies  as 
aromatic  spirits  of  ammonia,  ether,  strychnine,  digitalis,  or 
cocaine  may  prove  useful. 

Gh^ave  Nervous  Symptoms. — Delirium,  subsultus,  insomnia, 
etc.  may  be  due  to  fever  or  lack  of  stimulation ;  cold  bathing 
is  indicated  in  the  former,  and  the  free  use  of  alcohol  in  the 
latter.  Nerve  sedatives,  like  the  bromide  of  potassium,  musk, 
hyoscine,  sulphonal,  and  camphor,  are  sometimes  required. 

TYPHUS  FEVER. 

(Ship  Fever,  Jail  Fever.) 

Definition. — An  acute  contagious  disease  unassociated 
with  any  characteristic  lesions  of  the  solids,  and  manifested  by 
great  prostration,  a  petechial  rash,  marked  nervous  symptoms, 
and  high  fever  which  defervesces  by  crisis  in  from  ten  to 
fourteen  days. 

Etiology. — It  is  excited  by  an  unknown  poison  which  is 
capable  of  being  carried  in  clothes  (fomites).  It  is  rare  in 
America,  but  not  uncommon  in  England  and  Ireland.  Bad 
food,  impure  water,  overcrowding,  and  foul  air  are  predis- 
posing factors. 


244  ACUTE  INFECTIOUS  DISEASES. 

Pathology. — There  are  no  characteristic  lesions  of  the 
solids.  As  in  other  fevers,  the  liver  and  spleen  are  swollen, 
and  the  tissues  reveal  fatty  and  parenchymatous  degeneration. 
The  blood  shows  a  peculiar  change  :  it  is  dark,  fluid,  and 
stains  the  lining  of  the  heart  and  great  bloodvessels  bright  red. 

Period  of  Incubation. — A  few  hours  to  two  weeks. 

Fig.  18. 


Temperature  chart  of  typhus. 

f  Symptoms. — Typhus  fever  begins  abruptly  with  pain  in 
the  head,  back,  and  limbs ;  extreme  prostration ;  and  fever 
which  reaches  its  maximum  (104°-105°)  in  two  or  three  days. 
The  temperature  remains  high  for  about  ten  days,  when  it 
falls  by  crisis. 

The  pulse  is  rapid,  weak,  and  often  dicrotic.  The  tongue 
is  tremulous,  and  usually  covered  with  a  whitish  fur ;  but  in 
bad  cases  it  becomes  black  and  rolled  up  like  a  ball  in  the  back 
of  the  mouth. 

The  face  is  dusky ;  the  conjunctivae  are  injected ;  and  the 
pupils  are  contracted. 

Nervous  Symptoms. — These  are  prominent,  and  consist  of 
headache,  stupor,  delirium,  subsultus  tendinum,  carphologia, 
and  coma  vigil. 

The  Eruption, — About  the  fourth  or  fifth  day  rose-colored 
spots  appear  over  the  body  ;  these  rapidly  become  hemorrhagic, 
or  petechial,  and  fail  to  disappear  on  pressure.  There  is  a 
distinct  relation  between  the  amount  of  eruption  and  the 
severity  of  the  attack.  In  addition  to  this  "  mulberry  rash," 
there  is  often  a  diffuse,  dark-red  subcuticular  mottling. 


RELAPSING   PEVER.  245 

Gastro-intestinal  Symptoms. — The  stomach  is  retentive,  and 
the  bowels  are  constipated. 

Urine. — The  urine  is  scanty,  high-colored,  and  often  albu- 
minous. 

Complications. — Hyperpyrexia,  catarrhal  pneumonia, 
hypostatic  congestion  of  the  lungs,  nephritis,  and  parotid 
abscess. 

Diagnosis.  Cerebrospinal  Meningitis.  —  In  this  aflFection 
the  pain  in  the  back  is  greater.  The  fever  is  very  irregular ; 
there  is  greater  tendency  to  opisthotonos  and  facial  palsies  ;  and 
the  eruption,  though  it  may  resemble  that  of  typhus,  is  incon- 
stant and  without  a  special  time  for  appearing. 

Typhoid  Fever. — The  resemblance  is  in  the  nervous  phe- 
nomena only.  In  typhoid  the  fever  rises  and  falls  very 
gradually ;  the  eruption  appears  later,  remains  rose-red,  and 
does  not  become  petechial ;  the  face  is  not  dusky,  the  eyes  are 
not  injected  ;  and  there  are  marked  abdominal  symptoms. 

Prognosis. — The  mortality  is  much  greater  than  in  typhoid 
fever.  Advanced  years  and  alcoholism  render  the  prognosis 
decidedly  unfavorable. 

Treatment. — Isolation  ;  absolute  rest ;  liquid  diet.  There 
is  no  specific  treatment.  Alcohol  is  nearly  always  required. 
Quinine  and  mineral  acids  are  useful  tonics. 

Pyrexia,  nervous  phenomena,  and  heart-failure  should  be 
treated  as  in  typhoid  fever. 

RELAPSING  FEVER. 

(Spirillum  Fever,  Famine  Fever.) 

Definition. — An  acute  contagious  disease  excited  by  the 
spirochsete  of  Obermaier,  and  characterized  by  paroxysms  of 
high  fever  which  last  five  or  six  days  and  are  followed  by  in- 
termissions of  a  similar  duration. 

Etiology. — The  exciting  cause  is  the  spirochsete  of  Ober- 
maier, a  spiral-shaped  microbe  three  or  four  times  as  long 
as  the  diameter  of  a  red  blood-corpuscle.  Bad  water,  poor 
food,  overcrowding,  and  foul  air  predispose  to  ej)idemics. 
The  disease  is  highly  contagious. 


246  ACUTE  INFECTIOUS  DISEASES. 

Pathology.  —  There  are  no  characteristic  lesions.  The 
liver  and  spleen  are  much  enlarged,  and  the  latter  is  frequently 
the  seat  of  infarctions.  There  is  usually  catarrhal  inflamma- 
tion of  the  stomach  and  bile-ducts.  The  spirochsete  is  found  in 
the  blood  during  life,  but  only  during  the  paroxysms ;  after 
death  it  is  found  in  all  the  organs. 

Period  of  Incubation. — Five  to  eight  days. 

Fig.  19. 


Temperature  curve  in  relapsing  fever. 

Symptoms. — The  disease  begins  abruptly  with  a  chill  fol- 
lowed by  fever,  which  reaches  its  maximum  (105°-106°)  in 
twenty-four  hours,  and  remains  high  for  from  five  to  seven 
days,  when  it  falls  by  crisis.  After  an  intermission  of  five  or 
six  days  it  again  rises  rapidly  and  remains  high  for  a  similar 
period.  Convalescence  usually  begins  at  the  end  of  the  second 
paroxysm,  but  it  may  not  begin  until  after  the  third  or  fourth. 
Other  noteworthy  symptoms  are  intense  pains  in  the  head, 
back,  and  limbs  ;  the  spirochsete  in  the  blood  ;  and  frequently 
jaundice. 

Complications. — Hyperpyrexia,  nephritis,  pneumonia,  and 
ophthalmia. 

Diagnosis.  Rheumatie  Fever. — The  history,  irregular  fever, 
acid  sweats,  and  the  absence  of  spirilli  and  of  jaundice  will 
serve  to  distinguish  rheumatism  from  relapsing  fever. 

Remittent  Fever. — In  this  disease  the  fever  remits,  but  does 
not  intermit ;  the  paroxysms  are  more  frequent ;  and  instead 
of  spirilli,  hsematozoa  are  found  in  the  blood. 


CEREBRO-SPmAL   FEVER.  247 

Yellow  Fever. — The  single  remission  on  the  second  or  third 
day,  the  bloody  vomit,  and  the  absence  of  spirilli  and  of  splenic 
enlargement  will  indicate  yellow  fever. 

Prognosis. — Favorable  in  uncomplicated  cases. 

Treatment. — Isolation  ;  rest ;  liquid  diet.  As  a  general 
tonic,  quinine  is  useful.  For  the  pains,  antipyrin,  phenacetin, 
or  morphia  may  be  given  internally,  and  rubefacients  used 
locally.  For  the  irritable  stomach  hot  fomentations  may  be 
applied  to  the  epigastrium,  and  small  doses  of  calomel  and 
soda  administered  internally. 

CEREBRO-SPINALi  FEVER. 

(Epidemic  Cerebro-Spinal  Meningitis,  Spotted  Fever.) 

Definition. — A  specific  infectious  disease  characterized 
anatomically  by  inflammation  of  the  cerebro-spinal  meninges, 
and  clinically  by  intense  pain  in  the  head,  back,  and  limbs, 
convulsions,  irregular  fever,  and  frequently  by  a  petechial 
eruption. 

Etiology. — The  disease  may  be  sporadic  or  epidemic. 
Overcrowding,  poor  food,  foul  air,  and  bad  drinking- water 
seem  to  predispose  to  epidemics.  Outbreaks  are  most  common 
in  the  winter  and  spring.  The  young  are  more  susceptible 
than  the  old.  The  disease  is  not  contagious  ;  the  method  of 
transmission  is  still  unknown. 

The  Exciting  Cause, — This  is  unquestionably  a  micro-organ- 
ism. Certain  diplococci  have  been  repeatedly  found  in  the 
exudations,  but  they  have  not  been  proven  to  be  the  exciting 
factors. 

Pathology. — In  most  cases  the  membranes  of  the  brain 
and  cord  are  deeply  congested  and  opaque.  Lymph  and  pus 
are  found  both  at  the  base  and  on  the  convexity  of  the  brain, 
especially  in  the  fissures  and  along  the  bloodvessels.  The 
spinal  meninges  present  similar  changes,  the  posterior  surface 
of  the  cord  being  particularly  involved. 

The  liver  and  spleen  are  engorged  and  the  muscles  reveal 
granular  degeneration.  In  rapidly  fatal  cases  the  lesions  are 
very  slight. 


248  ACtJTE  INFECTIOUS   DISEASES. 

Symptoms.  Common  Form. — The  disease  generally  begins 
abruptly  with  a  chill,  followed  by  vomiting  and  excruciating 
pain  in  the  head,  back,  and  limbs.  The  muscles  of  the  neck 
and  back  become  rigid  and  contracted,  so  that  the  head  is  bent 
backward  and  the  back  is  straightened ;  in  severe  cases  the 
body  may  be  arched  in  a  state  of  opisthotonos.  The  mind  is 
soon  affected  ;  delirium  is  rarely  absent,  and  in  severe  cases  it 
is  followed  by  stupor  and  coma. 

Involvement  of  the  Cranial  Nerves. — Pressure  of  the  exudate 
upon  the  cranial  nerves  may  produce  the  following  symptoms  : 
Nystagmus  (tremor  of  the  eyeball);  strabismus;  ptosis;  irregu- 
lar, sluggish  pupils  ;    and  partial  deafness  or  blindness. 

Involvement  of  the  Spinal  Nerves. — There  is  extreme  cutaneous 
hypersesthesia,  so  that  the  slightest  touch  excites  pain.  The 
muscles  of  the  extremities  are  stiff  and  may  twitch,  but  are 
rarely  palsied.  The  patellar  reflex  is  usually  diminished. 
The  joints  are  occasionally  red,  swollen,  and  painful. 

Febrile  Symptoms. — The  temperature  is  irregular  in  its 
course  and  indefinite  in  its  duration  ;  ordinarily  it  ranges  be- 
tween 101°  and  103°,  but  in  some  cases  it  is  almost  normal, 
and  in  others  it  is  very  high.  The  pulse  is  rapid  and  full ; 
the  bowels  are  constipated ;  and  the  urine  may  contain  albumin 
and  sugar.     Polyuria  is  an  occasional  symptom. 

The  Eruption. — The  eruption  is  neither  constant  nor  pecu- 
liar. In  many  cases  a  blotchy  purpuric  rash  appears  over  the 
entire  body.  Herpes  facialis  is  also  frequently  observed.  In 
other  cases  urticaria,  or  a  roseolar  or  erythematous  rash  ap- 
pears. 

The  duration  is  from  a  few  hours  to  several  weeks.  In 
favorable  cases,  convalescence  is  very  protracted. 

Fulminant  Form. — There  is  an  abrupt  onset  with  a  chill, 
followed  by  vomiting,  headache,  moderate  fever,  convulsions, 
a  petechial  or  purpuric  rash,  and  death  in  a  few  hours  from 
collapse. 

Abortive  Form. — The  disease  begins  abruptly  with  grave 
symptoms,  but  terminates  in  a  few  days  in  recovery. 

Intermittent  Form, — The  fever  is  characterized  by  inter- 
missions or  marked  remissions  which  occur  daily  or  every 
other  day. 


CEEEBRO-SPINAL   FEVER.  249 

Diagnosis.  Typhoid  Fever. — The  gradual  onset,  the  regu- 
lar fever,  the  diarrhoea  and  tympanites,  and  the  absence  of 
rigidity,  of  intense  pain  in  the  back  and  limbs,  of  facial  palsies 
and  of  herpes,  will  separate  typhoid  from  cerebro-spinal  fever. 

Typhus  Fever. — The  regular  fever,  the  absence  of  intense 
pain  in  the  back  and  limbs,  of  facial  palsies,  and  of  muscular 
rigidity,  will  distinguish  typhus  from  cerebro-spinal  fever. 

Acute  articular  rheiLmcdis^n  may  resemble  cerebro-spinal 
meningitis,  but  the  early  involvement  of  the  joints,  the  acid 
sweats,  and  the  absence  of  rigidity,  of  eruption,  and  of  facial 
palsies,  will  distinguish  it  from  cerebro-spinal  meningitis. 

Tuberculmis  Meningitis. — In  this  disease  the  onset  is  less 
abrupt ;  there  is  less  tendency  to  opisthotonos  ;  herpes  is  rare ; 
and  petechise  are  always  absent.  Tuberculous  meningitis  in 
the  adult  is  always  secondary  to  tuberculosis  elsewhere. 

Peognosis. — The  mortality  varies  in  different  epidemics 
from  20  to  80  per  cent.  The  prognosis  should  always  be 
guarded  ;  the  mildest  cases  may  prove  fatal.  Severe  cerebral 
symptoms  usually  indicate  a  fatal  termination. 

Complications  and  Sequels. — Defective  vision  from 
inflammation  of  the  cornea  or  retina,  or  from  atrophy  of  the 
optic  nerve ;  defective  hearing  from  inflammation  of  the 
auditory  nerve,  or  from  suppurative  inflammation  of  the 
internal  or  middle  ear;  pneumonia  ;  arthritis ;  aphasia ;  periph- 
eral palsies ;  chronic  hydrocephalus ;  and  persistent  head- 
ache from  chronic  meningitis. 

Treatment. — A  liquid  or  semi-liquid  diet.  Ice-bags  may 
be  applied  to  the  head  and  along  the  spinal  column.  Pain 
and  restlessness  should  be  relived  by  morphine,  bromides,  or 
chloral.  Morphine  is  especially  efficacious,  and  may  be  injected 
along  the  course  of  the  most  painful  nerve- trunks.  Dry  or 
wet  cups  over  the  spine  are  sometimes  useful.  Iodide  of 
potassium  (gr.  v-x  thrice  daily)  may  be  administered  internally. 
Dr.  Pepper  recommends  quinine  (gr.  v  thrice  daily)  with  the 
fluid  extract  of  ergot  (5j  every  three  or  four  hours).  When 
the  pulse  weakens,  stimulants  should  be  given  freely.  High 
fever  may  be  controlled  by  sponging  with  cold  water,  by  the 
cold  pack,  or  by  the  internal  use  of  phenacetiu  or  antipyrin. 


( 


250  ACUTE   INFECTIOUS   DISEASES. 

During  convalescence,  iodide  of  potassium  as  an  absorbent, 
tonics,  and  blisters  to  the  spine  are  indicated. 

MALAKIAL.  FEVER. 

(Chills  and  Fever,  Fever  and  Ague,  S-wramp  Fever.) 

Definition. — A  specific  non-contagious  disease,  invariably 
associated  with,  and  probably  excited  by,  the  hcematozoa  of 
Laveran,  and  characterized  by  splenic  enlargement,  by  fever 
with  periodic  intermissions  or  remissions,  and  by  a  tendency 
to  extreme  ansemia. 

Etiology. — A  warm  climate  and  the  summer  season,  a 
moist  atmosphere ;  low,  badly-drained  soil ;  and  decaying 
vegetable  matter  are  the  conditions  which  favor  the  develop- 
ment of  the  malarial  poison. 

Special  Predisposing  Causes. — Residents  in  the  lowlands  are 
more  liable  to  be  infected  than  those  who  dwell  on  the  hills ; 
one  attack  seems  to  predispose  to  others ;  visitors  to  malarial 
districts  are  more  susceptible  than  permanent  residents ;  in 
the  night  and  in  the  early  morning  the  air  is  thoroughly  im- 
pregnated with  the  miasm,  and  exposure  at  such  times  is  very 
apt  to  be  followed  by  infection. 

Exciting  Cause. — Certain  organisms  belonging  to  the  pro- 
tozoa, and  known  as  the  hcematozoa,  are  probably  the  exciting 
agents. 

Manifestations. — Malarial  intoxication  may  manifest  it- 
self, as  (1)  intermittent  fever ;  (2)  remittent  fever ;  (3)  perni- 
cious malarial  fever ;  and  (4)  chronic  malarial  cachexia. 

Pathology. — Various  forms  of  hsematozoa  are  noted,  some 
of  which  are  distinct  species,  while  others  represent  simply 
phases  of  existence  in  the  life-history  of  the  same  organism. 
A  small  colorless  amoeboid  body  enters  the  red  blood-corpuscle, 
increases  in  size,  and  becomes  pigmented  from  the  haemoglobin 
of  the  corpuscle.  When  the  host  is  destroyed  the  granules  of 
pigment  collect  in  the  centre  of  the  organism,  which  finally 
divides  into  a  number  of  small  hyaline  bodies,  each  of  which 
begins  a  new  cycle  of  existence.  The  chills  or  paroxysms 
occur  at  the  time  of  sporulation,  and  are  doubtless  due  to  the 
production  of  a  toxine.     The  parasite  of  tertian  intermittent 


MALARIAL   FEVER.  251 

fever  requires  forty-eight  hours  to  complete  its  cycle  of  exist- 
ence ;  heuce,  when  a  single  group  of  these  parasites  exists  in 
the  blood  paroxysms  occur  every  other  day.  If,  hoAvever, 
two  groups  coexist  and  sporulate  on  alternate  days,  a  paroxysm 
occurs  daily  [quotidian  intermittent  fever).  The  parasites  of 
quai'tan  intermittent  fever  require  seventy-two  hours  in  which 
to  develop  and  undergo  sporulation  ;  hence  a  single  group  of 
these  organisms  in  the  blood  excites  a  chill  every  fourth  day. 
When  two  groups  coexist  a  chill  occurs  on  two  successive 
days,  and  is  followed  by  a  daily  intermission.  When  three 
groups  coexist  a  chill  occurs  every  day  (quotidian  intermittent 
fever).  The  life-history  within  the  body  of  the  parasite  of 
remittent  fever  is  not  definitely  known.  Its  cycle  of  existence 
occupies  from  twenty-four  to  forty-eight  hours.  Organisms 
with  flagella  sometimes  develop  from  fully-grown  hsematozoa, 
but  their  significance  is  unknown. 

Fig.  20. 


^■(lO 


Various  forms  of  htematozoa. 


In  advanced  malaria  the  blood  shows  a  diminished  number 
of  red  blood-corpuscles  and  an  abundance  of  free  pigment 
(melansemia).  The  spleen  is  greatly  swollen  and  deeply  pig- 
mented (ague-cake) ;  the  liver  is  moderately  enlarged  and 
pigmented.  All  the  organs,  including  the  brain  and  spinal 
cord,  are  discolored  by  the  liberated  pigment. 

Intermittent  Fever. 

SvaiPTOMS. — The   characteristic  features  of  this  form  of\ 
malarial  infection  are :  The  intermittent  type  of  fever,  the  | 
enlargement  of  the  spleen,  the  hsematozoa  in  the  blood,  and 
the  occurrence  at  regular  intervals  of  paroxysms  divided  into 
three  stages — cold,  hot,  and  sweating. 


252  ACUTE  INFECTIOUS  DISEASES. 

Cold  Stage. — Malaise;  headache;  great  chilliness.  The 
features  are  pinciied ;  the  lips  are  blue ;  the  surface  of  the 
body  is  cold  and  covered  with  cutis  anserina  (goose-flesh), 
although  the  rectal  temperature  is  high  (104°-105°).  Vomit- 
ing may  occur.  The  chill  lasts  from  a  few  minutes  to  an 
hour  or  two. 

Hot  Stage. — The  surface  temperature  gradually  rises ;  the 
skin  becomes  hot ;  the  face  flushed  ;  the  eyes  injected  ;  and 
the  pulse  full  and  rapid.  The  temperature  in  the  axilla  may 
reach  106°  or  107°.  The  patient  complains  of  severe  pain  in 
the  head,  back,  and  limbs,  and  of  intense  thirst.  The  urine 
is  scanty  and  dark -colored.  This  stage  usually  lasts  from  one 
to  five  hours. 

Sweating  Stage. — The  fever  gradually  subsides;  the  pain 
grows  less ;  free  perspiration  follows ;  and  the  patient  falls  to 
sleep,  from  which  he  awakes  feeling  fairly  well. 

Varieties. — When  the  paroxysms  occur  every  day,  the 
disease  is-  termed  quotidian  intermittent;  every  other  day, 
tertian  intermittent;  every  fourth  day,  quartan  intermittent. 

Prognosis. — Always  favorable.  Even  when  no  treatment 
is  instituted  the  paroxysms  gradually  subside.  Chronic  ma- 
larial cachexia  sometimes  results  from  the  acute  disease. 

Remittent  Fever. 

(^stivo-autumnal  Fever,  Bilious  Remittent  Fever,  Jungle  Fever.) 

In  temperate  zones  remittent  fever  is  observed  chiefly  in  the 
autumn.  The  hsematozoa  appear  at  first  as  small  round  motile 
bodies  with  very  little  pigment  in  them,  but  soon  these  are 
replaced  by  ovoid  or  crescentic  bodies  containing  central 
masses  of  coarse  pigment. 

Symptoms. — Malaise  with  moderate  chilliness,  followed  by 
a  continuous  fever  which  daily  remits.  The  maximum  tem- 
perature ranges  from  103°  to  106°,  and  while  this  lasts  the 
skin  is  hot,  the  face  is  flushed,  the  eyes  are  injected,  the  pulse 
is  full  and  rapid,  the  urine  is  scanty,  and  the  patient  complains 
of  pain  in  the  head  and  limbs.  Definite  paroxysms  may  or 
may  not  be  present.  Delirium  is  sometimes  noted  ;  vomiting 
often  occurs ;  and  jaundice  may  develop  from  destruction  of 


MALARIAL  FEVER.  253 

the  red  blood-corpuscles  and  liberation  of  their  pigment.  The 
spleen  is  enlarged,  and  an  examination  of  the  blood  reveals 
hsematozoa. 

In  some  cases  the  symptoms  resemble  typhoid  fever,  and  to 
these  the  term  typho-malarial  fever  has  been  applied. 

Diagnosis.  Typhoid  Fever. — The  absence  of  diarrhoea,  of 
tympanites,  of  eruption,  and  of  a  gradual  rise  in  temperature, 
and  the  presence  of  lisematozoa  and  of  marked  remissions  will 
serve  to  separate  remittent  fever  from  typhoid. 

Yellow  Fevei\ — The  splenic  enlargement,  the  haematozoa, 
the  multiple  remissions,  and  the  absence  of  bloody  vomit  will 
separate  remittent  from  yellow  fever. 

Prognosis. — Favorable ;  the  average  duration  is  from  one 
to  two  weeks. 

Pernicious  Malarial  Fever. 

(Congestive  Chills,  Malignant  Malaria.) 

Pernicious  malarial  fever  is  found  chiefly  in  the  tropics. 
It  is  invariably  associated  with  the  parasite  of  remittent 
fever.  There  are  three  varieties :  algid,  comatose,  and  hem- 
orrhagic. 

Symptoms.  Algid. — The  symptoms  resemble  the  cold 
stage  of  cholera.  The  surface  is  cold ;  the  temperature  may 
be  subnormal ;  there  is  great  prostration ;  the  features  are 
pinched ;  the  pulse  is  feeble.  Vomiting  and  jDurging  may 
follow  ;  death  often  results  in  collapse. 

Comatose. — There  is  delirium,  rapidly  followed  by  stupor 
and  coma ;  the  latter  may  or  may  not  be  associated  with  con- 
vulsions. The  skin  is  hot ;  the  face  is  flushed ;  the  eyes  in- 
jected ;  and  the  temperature  high.  The  symptoms  gradually 
disappear,  but  unless  the  patient  is  speedily  cinchonized  they 
return  and  commonly  prove  fatal. 

Hemorj'hagic. — In  this  form  hemorrhages  occur  from  the 
mucous  membranes,  especially  from  the  kidneys,  stomach,  and 
bowels,  and  the  patient  is  frequently  jaundiced. 

Diagnosis. — The  algid  form  may  resemble  cholera,  but  the 
history,  the  absence  of  an  epidemic,  and  the  presence  of  the 
hsematozoa  in  the  blood  will  render  the  diagnosis  apparent. 


~) 


254  ACUTE  INFECTIOUS  DISEASES. 

Yelloic  Fever. — The  hemorrhagic  form  may  resemble  yellow 
fever,  but  the  splenic  enlargement,  the  late  appearance  of  jaun- 
dice, the  presence  of  hsematozoa  in  the  blood,  and  the  absence 
of  an  epidemic  will  serve  to  distinguish  the  two  diseases. 

Prognosis. — Extremely  guarded  ;  the  first  paroxysm  rarely 
kills,  but  unless  the  patient  is  thoroughly  cinchonized  a  second 
one  may  prove  fatal. 

Chronic  Malarial  Cachexia. 

Definition. — A  chronic  manifestation  of  malaria,  charac- 
terized by  anaemia,  by  a  sallow  appearance  of  the  skin,  and  by 
splenic  enlargement. 

Etiology. — It  may  result  from  repeated  attacks  of  the 
acute  disease,  or  it  may  develop  as  a  primary  condition  from 
slow  infection. 

Symptoms. — The  patient  is  thin  and  pale ;  the  complexion 
is  of  a  dirty  yellow  or  muddy  hue ;  fever  is  often  absent ;  if 
present,  it  is  slight  and  irregular ;  the  spleen  is  considerably 
enlarged.  There  is  great  weakness  from  the  attending  anaemia. 
Headache  and  neuralgia  are  common  symptoms.  Hsematuria 
is  sometimes  observed. 

Diagnosis.  Leuccemia. — The  history,  the  absence  of  leuco- 
cytosis  and  of  lymphatic  enlargements,  and  the  presence  of 
hgematozoa  in  the  blood  will  indicate  malaria. 

Prognosis. — Guarded.  When  the  spleen  is  very  large  and 
there  is  extreme  anaemia,  recovery  rarely  follows. 

Other  Manifestations  of  Malaria. 

One  of  the  following  conditions  may  be  the  chief  manifes- 
tation of  malarial  intoxication  :  Neuralgia,  headache,  hsema- 
turia,  purpura,  orchitis,  or  paraplegia. 

Malarial  infection  seems  to  predispose  to  certain  cases  of 
dysentery,  of  pneumonia,  and  of  amyloid  degeneration  of  the 

viscera. 

Treatment  of  Malarial  Diseases.  Prophylaxis. — 
Patients  living  in  malarial  districts  should  avoid  the  night 
and  early  morning  air,  and  should  take  quinine  (gr.  iij-v  a 
day)  during  the  season  in  which  the  disease  is  prevalent. 


MALARIAL   FEVEK.  255 

Cold  Stage  of  Intermittent. — Cover  the  patient  with  blankets, 
and  apply  hot  cans  or  hot  bottles  to  the  feet.  When  the  chill  is 
severe  and  prolonged,  morphine  is  very  useful ;  it  may  be  given 
hypodermically.  Hoifmann's  anodyne  may  be  employed 
as  a  substitute.  Inhalations  of  nitrite  of  amyl  are  followed ' 
by  dilatation  of  the  superficial  bloodvessels,  and  in  this  way 
serve  to  shorten  the  chill. 

Hot  Stage  of  Intermittent. — Sponge  the  body  with  cool 
water,  and  if  the  symptoms  are  severe  phenacetin  may  be 
given  to  lower  the  temperature  and  to  lessen  the  pain. 

The  Interval. — It  is  well  to  begin  the  treatment  by  the^ 
administration  of  a  laxative,  and  calomel  may  be  selected. 
This  should  be  followed  by  quinine  (gr.  xv— xx)  in  divided 
doses,  so  that  the  last  dose  is  taken  two  hours  before  the  time 
of  the  expected  paroxysm.  In  children,  quinine  may  be  given 
in  lozenges  made  with  chocolate  and  sugar.  In  adults,  it  is 
best  administered  in  fresh  pills  or  in  capsules.  These  doses 
of  quinine  should  be  continued  until  the  paroxysms  disappear, 
when  the  amount  may  be  gradually  diminished.  The  treat- 
ment should  be  continued  for  several  weeks.  During  conva- 
lescence it  is  advisable  to  give  arsenic  in  the  form  of  Fowler's 
solution  with  the  quinine.  The  following  pill  is  also  useful 
in  the  convalescence  of  malaria  : — 

^  Acid,  arsenosi,   gr.  ss  ; 

Quiniu.  sulph.,  3j  ; 

Ferri  pyrophos. ,  gr.  xxx  ; 

Pulv.  capsici,  gr.  xv. — M. 
Ft.  in  pil.  No.  xxx. 
Sig. — One  thrice  daily. 

Remittent  Fever. — Absolute  rest.  A  light  diet.  Quinine 
(gr.  xx-xxx)  should  be  given  in  divided  doses  in  the  course 
of  a  day.  A  laxative  dose  of  calomel  is  a  valuable  adjunct  to 
the  antiperiodic  treatment.  When  the  stomach  is  irritable 
calomel  and  soda  may  be  given  by  the  mouth,  and  the  quinine 
by  the  rectum  or  hypodermically.  In  some  cases  Warburg's 
tincture  is  useful;  half  an  ounce  undiluted  may  be  given,  and 
repeated  in  two  or  three  hours.  After  its  administration  the 
patient  should  be  thoroughly  covered  with  blankets  so  as  to 
favor  free  diaphoresis. 


256  ACUTE  INFECTIOUS   DISEASES. 

Pernicious  Malarial  Fever. — From  fifty  to  a  hundred  grains 
of  quinine  must  be  given  before  the  second  paroxysm  occurs. 
It  is  advisable  to  begin  at  once  without  waiting  for  the  inter- 
mission ;  and  twenty  to  thirty  grains  may  be  given  hypoder- 
mically  every  two  or  three  hours. 

^  ^   Quininee  sulph.,  gr.  xl ; 

Sat.  sol.  acid,  tartar.,  TTlxlviij  ; 
Aquae  destil.,  q.  s.  ad  f^ij.— M. 
Sig. — 1Tlxxx=gr.  X. 

When  the  pulse  weakens,  stimulants,  like  whiskey,  ammonia, 
and  strychnine,  should  be  employed.  High  temperature  should 
be  controlled  by  the  external  application  of  cold.  In  the 
algid  form,  heat  should  be  applied  externally,  and  opium 
given  by  the  mouth  or  hypodermically.  In  the  hemor- 
rhagic form,  opium  is  also  useful,  and  it  may  be  associated 
with  haemostatics  like  turpentine,  erigeron,  or  hamamelis. 

Chronie  Malarial  Cachexia. — Iron,  quinine,  and  arsenic  are 
the  remedies  indicated. 


SCARLET  FEVER. 

(Scarlatina.) 

Deflnition. — An  acute  contagious  disease,  characterized 
by  high  fever,  a  rapid  pulse,  a  punctiform  scarlet  rash,  sore 
throat,  and  an  unusual  tendency  to  nephritis. 

Etiology. — The  specific  poison  of  scarlet  fever  has  not  been 
isolated.  The  contagium  is  usually  carried  through  clothes  or 
other  fomites,  or  in  food  like  milk.  The  disease  can  be 
transmitted  by  direct  inoculation.  The  poison  is  tenacious 
and  of  extreme  vitality  ;  infected  clothes,  unused  for  years, 
have  led  to  outbreaks.  The  young  are  especially  predisposed, 
but  not  equally  so.  Puerperal  women  and  persons  suffering 
from  wounds  are  unusually  susceptible.  One  attack  does  not 
give  absolute  immunity,  but  second  attacks  are  uncommon. 

Pathology. — The  throat  is  inflamed  and  sometimes  ulcer- 
ated ;  the  liver  and  spleen  are  engorged  ;  the  muscles  reveal 
granular  degeneration.  Klein  has  observed  hypersemia  and 
cell-proliferation,  not  only  in  the   throat  and  kidneys,  but 


SCAELET  FEVER.  257 

throughout  the  intestinal  canal.  The  kidneys  frequently  show 
the  lesions  of  hemorrhagic  nephritis,  the  glomeruli  being  espe- 
cially involved.     The  rash  is  rarely  detected  after  death. 

Vaeieties. — (1)  Simple ;  (2)  anginoid  ;  (3)  malignant. 

Period  of  Incubation. — A  few  hours  to  a  week. 

Symptoms. — The  disease  generally  begins  suddenly,  occa- 
sionally with  a  chill,  but  more  commonly  with  vomiting  or 
convulsions. 

Throat  SymptoTns. — Pain  and  difficulty  in  swallowing  ;  ful- 
ness and  tenderness  beneath  the  jaw ;  enlargement  of  the 
lymphatic  glands.  The  tongue  is  at  first  heavily  coated  and 
red  at  the  tip  and  edges ;  in  a  few  days  the  coating  almost 
entirely  disappears,  and  the  papillae  become  bright  red  and 
swollen.  This  appearance  has  given  rise  to  the  term  "  straw- 
berry tongue."  The  pillars,  tonsils,  uvula,  and  pharyngeal 
vault  are  deeply  injected  and  may  reveal  a  punctiform  efflo- 
rescence before  the  rash  develops  on  the  skin.  In  severe  cases 
the  tonsils  may  be  the  seat  of  follicular  inflammation,  or  may 
be  covered  with  false  membrane. 

Eruption. — A  scarlet-red  punctiform  rash  appears  at  the  end 
of  the  first,  or  at  the  beginning  of  the  second  day,  on  the  neck 
and  chest,  and  rapidly  spreads  over  the  entire  body.  It  dis- 
appears on  pressure,  a  white  line  remaining  for  a  second  or  two 
when  the  finger-nail  is  drawn  through  it.  It  may  be  uniform 
or  it  may  occur  in  discrete  patches  surrounded  by  healthy  skin. 
In  five  or  six  days  the  red  color  gradually  fades  and  scaly 
desquamation  soon  follows. 

In  some  cases  the  rash  is  pale  and  scarcely  visible,  in  others 
it  is  slightly  papular  or  vesicular  (scarlatina  miliaris)  ;  in  ma- 
lignant cases  it  may  be  petechial. 

Febrile  Symptoms. — The  fever  rises  abruptly,  reaching  its 
maximum  (104°-105°)  in  twenty-four  or  forty-eight  hours, 
remains  nearly  uniform  for  three  or  four  days,  and  then  falls 
by  lysis.  The  duration  of  the  febrile  period  is  from  seven  to . 
nine  days.  The  pulse  is  very  rapid, — out  of  proportion  to  the 
fever ;  the  respirations  are  hurried ;  the  appetite  is  lost ;  the 
bowels  are  constipated ;  and  the  urine  is  scanty,  high-colored, 
and  often  contains  albumin. 
17 


258  ACUTE  INFECTIOUS  DISEASES. 

Nervmis  Symptoms. — EiGstlessness,  headache,  insomnia,  de- 
lirium, and  convulsions  may  occur  in  the  course  of  the  disease. 
Convulsions  developing  late  in  the  disease  are  very  significant 
of  ursemia. 

Anginoid  Scarlet  Fever. — This  form  is  characterized  by 
severe  throat  symptoms.  The  tonsils  are  much  swollen  and 
are  often  covered  with  false  membrane.  The  fever  is  high 
and  the  prostration  is  profound.  Ulceration  of  the  throat  fre- 
quently occurs.  Death  may  result  from  exhaustion,  asj^iration- 
pneumonia,  or  from  hemorrhage  due  to  ulceration  of  the 
carotid  artery. 

Malignant  Scarlet  Fever. — The  onset  is  abrupt,  with  a  chill, 
vomiting,  or  convulsion  ;  the  fever  is  very  high  (106°-107°)  ; 
the  pulse  is  rapid  and  feeble ;  delirium  sets  in,  and  is  followed 
by  coma.  Death  may  result  before  the  appearance  of  the 
rash,  in  twenty-four  or  forty-eight  hours. 

Complications.  Nephtntis. — This  usually  develops  during 
convalescence,  and  as  it  may  be  unassociated  with  subjective 
symptoms  the  urine  should  be  examined  daily  in  order  to  de- 
tect its  presence ;  in  other  cases  its  advent  is  recognized  by  the 
suppression  of  urine,  by  ursemia,  or  by  dropsy.  Nephritis 
may  be  the  immediate  cause  of  death,  but  more  commonly  it 
ends  in  recovery ;  it  sometimes  leads  to  chronic  renal  disease. 

Among  other  complications  may  be  mentioned  hyperpyrexia, 
endocarditis,  pericarditis,  pneumonia,  suppuration  of  the  lym- 
phatic glands,  ophthalmia,  inflammation  of  the  middle  ear, 
chorea,  and  a  peculiar  inflammation  of  the  joints  resembling 
rheumatism. 

Diagnosis. — Acute  Tonsillitis  may  resemble  scarlet  fever, 
especially  when  the  former  is  associated  with  an  erythematous 
rash ;  but  in  tonsillitis  there  is  no  history  of  contagion,  the 
pulse  is  proportionate  to  the  fever;  the  rash,  if  present,  is  not 
punctiform;  the  tongue  has  not  the  strawberry  appearance;  and 
there  is  no  tendency  to  nephritis. 

Diphtheria. — The  onset  is  less  abrupt ;  there  is  more  pros- 
tration ;  false  membrane  is  always  present ;  a  cutaneous  rash 
is  usually  absent ;  and  the  tongue  does  not  present  a  straw- 
berry appearance. 

Measles. — The  sore  throat  is  less  marked  ;  catarrhal  symp- 
toms are  present ;  the  rash  appears  later,  is  papular,  and  forms 


SCAELET  FEVER.  259 

in  crescentic-shaped  patches ;  the  fever  shows  a  decided  remis- 
sion on  the  second  or  third  day ;  and  the  pulse  is  proportionate 
to  the  fever. 

Rotheln. — This  may  be  difficult  to  distinguish  from  scarla- 
tina, but  the  fever  is  not  so  high,  nor  the  pulse  so  rapid ;  the 
post-cervical  glands  are  more  swollen  ;  there  is  no  tendency  to 
nephritis ;  and  the  rash  is  not  punctiform. 

Accidental  Rashes. — Certain  drugs  like  belladonna,  quinine, 
and  copaiba,  and  certain  foods,  like  crabs  and  oysters,  may 
produce  a  rash  like  that  of  scarlet  fever,  but  it  is  not  puncti- 
form, and  is  not  associated  with  high  fever,  sore  throat,  and 
rapid  pulse. 

Prognosis. — Always  guarded.  The  mortality  varies  in 
different  epidemics  from  5  to  40  per  cent. 

Treatment.  —  Isolation.  Absolute  rest.  Liquid  diet. 
The  surface  of  the  body  should  be  anointed  two  or  three  times 
daily  with  cold  cream,  cocoa-butter,  or  carbolized  vaseline. 
The  patient  should  be  encouraged  to  drink  water  or  lemonade 
freely.  Gastric  irritability  may  call  for  small  doses  of  calo- 
mel, bismuth,  or  nitrate  of  silver.  When  the  stomach  is 
retentive,  the  tincture  of  the  chloride  of  iron  may  be  given 
with  small  doses  of  dilute  hydrochloric  acid,  thus: — 

J^:..  Tinct.  ferri  chlor.,  fgij  ; 
Acid,  hydrochlor.  dil.,  f^j  ; 
Syr.  limonis,  fgj  ; 
Aquse,  q.  s.  ad  f  ^iij. — M. 
Sig. — Teaspoonful  in  water  every  two  or  three  hours. 

The  fauces  and  pharynx  should  be  kept  clean  by  antiseptic ' 
washes  or  sprays,  such  as  Dobell's  solution,  dilute  peroxide  of 
hydrogen,  or  dilute  listerine. 

Cerebral  symptoms  may  be  controlled  by  bromide  of  potas- 
sium, chloral,  by  an  ice-bag  to  the  head,  or,  when  due  to 
fever,  by  the  cold  bath. 

High  fever  is  best  treated  by  sponging,  by  the  cold  pack, 
or  by  the  graduated  cold  bath. 

The  urine  should  be  examined  daily  for  evidence  of  ne- 
phritis, and,  if  the  latter  arises,  the  diet  should  be  cut  down 
to  skimmed  milk  or  buttermilk  ;  dry  cups  may  be  applied  to 
the  loins  ;  the  bowels  kept  active  by  Epsom  or  Rochelle  salt ; 
and  diaphoresis  encouraged  by  small  doses  of  jaborandi. 


260  ACUTE  INFECTIOUS  DISEASE^. 

Cardiac  weakness  will  call  for  stimulants  like  alcohol,  am- 
monia, strychnine,  and  digitalis. 

Convalescence  should  be  guarded  and  protracted. 

MEASLES. 

(Rubeola,  Morbilli.) 

Definition. — An  acute  contagious  disease,  characterized 
by  catarrh  of  the  respiratory  tract,  moderate  fever,  and  a  red 
papular  eruption,  which  appears  on  the  fourth  day  and  termi- 
nates in  two  or  three  days  by  branny  desquamation. 

Etiology. — Measles  is  highly  contagious,  and  the  poison 
may  be  transmitted  through  clothes  and  other  fomites.  The 
contagium  is  apparently  associated  with  the  nasal  and  bron- 
chial secretion,  but  it  has  not  been  isolated.  It  is  most 
commonly  observed  in  children,  but  unprotected  adults  are 
very  liable  to  be  attacked.  It  is  essentially  an  epidemic  dis- 
ease, but  now  and  then  sporadic  cases  occur.  One  attack  is 
fairly  protective,  but  does  not  give  absolute  immunity. 

Pathology. — The  lesions  consist  in  catarrh  of  the  entire 
respiratory  tract.  Gastro-intestinal  catarrh  is  not  uncommon. 
In  fatal  cases  such  complications  as  capillary  bronchitis, 
catarrhal  pneumonia,  and  pulmonary  collapse  are  frequently 
observed. 

Period  of  Incubation. — About  two  weeks. 

Symptoms.  Prodromes. — Chilliness,  coryza,  watering  of  the 
eyes,  photophobia,  cough,  and  drowsiness. 

The  Fever. — The  temperature  rises  rapidly  to  102°  or  103°, 
but  on  the  second  day  there  is  a  decided  remission  which 
continues  until  the  fourth  day,  when  the  eruption  appears  ;  at 
this  time  it  again  rapidly  runs  up  to,  or  beyond,  its  original 
height  where  it  remains  for  two  or  three  days  and  then  falls 
by  crisis. 

The  Catarrh. — Redness  of  the  conjunctivse,  lachrymation, 
sneezing,  hoarseness,  cough,  and  expectoration.  There  may 
^  be  vomiting  or  diarrhoea. 

The  Eriuptlon. — This  appears  about  the  fourth  day  on  the 
face,  and  rapidly  spreads  over  the  entire  body.  It  is  com- 
posed of  small,  dark-red,  velvety  papules,  which  form  groups 


T. 


MEASLES.  261 

having  crescentic  borders.  Red  spots  are  frequently  noticed 
on  the  pharynx  before  the  eruption  develops  on  the  skin.  In 
two  or  three  days  the  eruption  begins  to  fade,  and  branny 
desquamation  soon  follows. 

Malignant,  or  Hemorrhagic  Measles. — This  form  occurs 
under  bad  hygienic  conditions,  and  is  characterized  by  a  pete- 
chial rash,  by  hemorrhages  from  the  mucous  membranes,  and 
by  profound  prostration. 

Complications  and  Sequels.  —  Capillary  bronchitis, 
catarrhal  pneumonia,  tuberculosis,  otitis,  gastro-intestinal 
catarrh,  cancrum  oris,  and  paralysis. 

Diagnosis.  Rotheln. — Prodromes  are  often  absent ;  fever 
and  catarrh  are  slight;  sore  throat  is  marked.  The  rash 
appears  on  the  first  or  second  day  as  a  diffuse  red  bhish,  or 
as  small  pale-red  spots  which  do  not  form  crescentic-shaped 
patches ;  desquamation  is  scarcely  noticeable. 

Scarlet  Fever. — The  fever  is  high  and  lacks  the  pre-emptive 
remission ;  sore  throat  is  present  instead  of  general  catarrh ; 
the  eruption  appears  on  the  first  or  second  day  as  a  diffuse 
punctiform  rash ;  the  pulse  is  out  of  proportion  to  the  fever ; 
and  there  is  much  greater  tendency  to  nephritis. 

Prognosis. — Guardedly  favorable.  Complications  are  apt 
to  occur  and  render  the  prognosis  grave. 

Treatment. — Isolation .  A  darkened  well-ventilated  room ; 
absolute  rest.  A  liquid  diet.  Such  refrigerant  remedies  as 
sweet  spirits  of  nitre  and  liquor  ammonise  acetatis  are  indicated 
and  may  be  combined  with  a  little  aconite. 

"^  Spt.  sether.  nitrosi,   ff  ss  ; 

Liq.  amnion,  acetatis,  q.  s.  ad  f,f  iij. — M. 
Sig. — A  teaspoonful  every  two  hours. 

For  the  bronchial  catarrh,  apply  a  cotton  jacket  to  the  chest  > 
and  give  internally  expectorants  with  sedatives  like  paregoric 
or  bromide  of  potassium. 

R     Liq.  potass,  citrat.,  f^iss ; 
Tinct.  opii  camph.,  f^iij  ; 
Syr.  ipecac,  f^j ; 
Syr.  acaciie,  ff  ss  ; 
Aquse,  q.  s.  ad  f.^iij. — M. 
Sig. — A  dessertspoonful  every  two  hours  for  a  child  of  five  years. 


262  ACUTE   INFECTIOUS   DISEASES. 

Gastric  irritability  should  be  relieved  by  small  doses  of  bis- 
muth or  by  calomel  and  soda.  During  desquamation  the  skin 
should  be  anointed  two  or  three  times  daily.  High  fever  is 
best  controlled  by  sponging  with  tepid  water.  During  con- 
valescence nutrients  like  cod-liver  oil  and  malt,  and  tonics  like 
iron,  quinine,  and  strychnine  are  indicated. 

ROTHELN. 

(Rubella,  German  Measles,  Epidemic  Roseola.) 

Definition. — An  acute  contagious  disease  resembling  both 
scarlet  fever  and  measles,  but  differing  from  these  in  its  short 
course,  slight  fever,  and  freedom  from  sequelse. 

Etiology. — The  disease  is  highly  contagious,  and  the 
poison  may  be  carried  on  clothes  or  other  fomites.  It  gener- 
ally occurs  in  epidemics,  but  sporadic  cases  are  not  uncommon. 
It  is  most  frequently  observed  in  children,  but  unprotected 
adults  are  not  exempt.  One  attack  usually  protects  from 
another,  but  not  from  measles  or  scarlet  fever. 

Period  of  Incubation. — About  two  weeks. 

Symptoms. —  Prodromes  are  slight,  or  altogether  absent. 
The  disease  begins  with  drowsiness,  slight  fever,  and  sore 
throat.  The  eruption  appears  on  the  first  or  second  day,  and 
varies  considerably  in  its  character.  In  some  cases  the  rash 
is  composed  of  pale-red,  scarcely  elevated  papules,  which  are 
more  or  less  discrete  {rubella  morbillifcn'me) ;  in  others  the  rash 
is  bright  red  and  diffuse  like  that  of  scarlet  fever  {rubella  scar- 
latiniforme).  It  begins  on  the  face  and  rapidly  spreads  over 
the  entire  body,  but  it  fades  so  rapidly  that  the  face  may  be 
clear  before  the  extremities  are  affected.  Slight  desquamation 
frequently  follows,- though  it  is  often  absent.  Apart  from  the 
sore  throat,  the  catarrhal  symptoms  are  slight.  The  super- 
ficial cervical  and  posterior  auricular  glands  are  more  swollen 
than  in  measles. 

The  duration  is  from  three  to  five  days. 

Prognosis. — Good.     Complications  are  rare. 

Treatiment. — Rest.  Liquid  diet.  Refrigerants.  Spong- 
ing with  tepid  water. 


SMALLPOX.  263 

SMAI.LPOX. 

(Variola.) 

Definition. — An  acute  contagious  disease,  characteVized  by 
vomiting ;  lumbar  pains;  an  eruption  which  is  at  first  papular, 
then  vesicular,  and  finally  pustular ;  and  by  fever  which  is 
marked  by  a  distinct  remission  beginning  with  the  advent  of 
the  eruption,  and  lasting  until  the  latter  becomes  pustular. 

Etiology. — The  poison  of  smallpox  is  extremely  tenacious  ; 
it  may  remain  latent  in  clothes  or  other  fomites  for  a  long  time, 
and  then  be  capable  of  exciting  the  disease.  The  virulent 
principle  is  doubtless  contained  in  the  pustules  and  in  all  the 
excretions  of  the  body,  but  it  has  not  been  isolated.  Unless 
protected  by  vaccination  or  a  previous  attack,  nearly  every  one 
is  susceptible,  from  the  aged  to  the  child  in  utero.  The  colored 
race  seem  especially  predisposed. 

Pathology. — The  eruption  consists  in  an  infiltration  of 
cells  into  the  rete  mucosum  or  into  the  true  skin.  The  cells 
ultimately  undergo  liquefaction-necrosis,  when  suppuration 
soon  follows.  Genuine  pocks  are  frequently  found  in  the 
moUth,  oesophagus,  and  larynx,  and  rarely  in  the  stomach, 
trachea,  and  bronchi.  The  spleen  is  engorged.  The  organs 
and  muscles  reveal  fatty  and  parenchymatous  degeneration. 
/  Varieties. — Discrete ;  confluent ;   malignant ;  varioloid. 

Fig.  21. 


Temperature  Curve  in  Smallpox. 


Symptoms.  Discrete  Smallpox.  —  The  disease  usually 
begins  with  a  chill  or  series  of  chills,  followed  by  vomiting  and 
int-ense  lumbar  pains.     The  fever  rises  rapidly,  reaching  its- 


264  ACUTE  INFECTIOUS   DISEASES. 

maximum  (104°-105°)  in  forty-eight  hours,  and  continues 
high  until  the  third  or  fourth  day,  when  it  falls  several  degrees  ; 
this  remission  lasts  until  the  seventh  or  eighth  day, — that  is, 
the  time  of  pustulation, — when  it  again  rises.  The  secondary 
or  suppurative  fever  shows  marked  fluctuations  ;  its  height  is 
proportionate  to  the  number  of  pustules  ;  and  it  falls  by  lysis 
about  the  eighteenth  day  of  the  disease.  The  pulse  is  full  and 
rapid  (120-140)  ;  the  breathing  is  hurried  ;  the  skin  is  dry  ; 
the  bowels  are  usually  constipated,  though  diarrhoea  is  not  un- 
common ;  and  the  urine  is  scanty  and  frequently  albuminous. 

The  Eruption. — About  the  third  or  fourth  day  small  red 
spots  are  noticed  on  the  forehead,  face,  and  wrists ;  these  are 
rapidly  converted  into  smooth  round  papules  which  feel  like 
shot  under  the  skin.  The  eruption  rapidly  spreads  over  the 
entire  body.  About  the  third  day  the  papules  are  converted 
into  clear  vesicles,  which  present  a  depression  or  umbilication 
at  their  summit.  They  are  also  loculated,  i.  e.  divided  into 
compartments  by  fibrinous  partitions,  so  that  when  pricked 
with  a  needle  all  of  the  contained  fluid  does  not  escape.  In 
two  or  three  days  the  clear  fluid  becomes  turbid  and  the 
vesicles  are  gradually  converted  into  pustules.  The  latter 
soon  lose  the  umbilicated  appearance.  Between  the  lesions 
the  skin  is  oedematous,  so  that  the  body  is  swollen  and  the 
features  are  unrecognizable.  In  three  days  more  the  pustules 
dry  up,  or  break  and  form  soft  yellow  crusts  which  exhale  a 
peculiar,  offensive  odor ;  they  adhere  to  the  skin  for  a  week  or 
more.  When  the  scabs  fall  off",  scars,  or  pock-marks  generally 
remain,  constituting  a  permanent  deformity. 

At  the  beginning  of  the  disease,  before  the  true  variolous 
eruption  appears,  either  a  red  blush  or  a  macular  rash  is  often 
observed  on  the  inner  side  of  the  arms  and  thighs. 

Confluent  Smallpox. — The  papules  are  abundant,  and  soon 
coalesce.  The  extremities  are  swollen  and  painful.  The 
secondary  fever  is  very  high  and  irregular.  True  pocks  nearly 
always  develop  in  the  air-passages  and  give  rise  to  a  copious 
fetid  discharge  from  the  nose  and  throat,  to  hoarseness,  and  to 
cough.  Delirium,  stupor,  and  subsultus  are  frequent  symp- 
toms.    If  the   patient  recovers,   it  is   after  a  tedious   con- 


SMALLPOX.  265 

valescence,  with   great  facial   disfigurement,  and  often  with 
defective  vision  and  hearing. 

Malignant  Smallpox. — In  some  cases  the  disease  is  ushered 
in  with  high  fever,  lumbar  pains,  and  great  prostration.  Soon 
ecchymoses  appear  on  the  skin ;  bleeding  from  the  mucous 
membranes  follows  ;  and  death  results  before  a  true  variolous 
rash  appears.  In  other  cases  the  disease  advances  like  or- 
dinary smallpox  up  to  the  pustular  stage  ;  then  the  pustules 
become  effused  with  blood,  and  bleeding  from  the  mucous 
membrane  follows.     This  form  is  also  very  fatal. 

Varioloid. — This  is  modified  smallpox  occurring  in  one  who  \ 
has  been  partially  protected  by  previous  vaccination.     The 
symptoms  are  mild ;  the  eruption  resembles  that  of  common 
smallpox,   but    is    usually  very   scant;    secondary    fever   is 
absent. 

Complications  and  Sequels. — Broncho-pneumonia; 
pleurisy;  inflammations  of  the  eye  (keratitis,  iritis,  conjunc- 
tivitis) ;  otitis ;  arthritis ;  and  boils. 

Diagnosis.  Varicella. — The  symptoms  are  milder;  pro- 
dromes are  generally  absent ;  the  eruption  appears  earlier,  is 
more  superficial,  lacks  an  inflammatory  areola,  and  is  not 
umbilicated. 

Secondary  Syphilis. — The  history ;  the  absence  of  fever ; 
the  symmetrical  distribution  of  the  eruptiou ;  its  dark- 
coppery  color;  its  polymorphous  character  (papules,  vesicles, 
and  pustules  associated  in  a  limited  area)  ;  and  the  absence 
of  itching  will  indicate  syphilis. 

Prognosis. — This  depends  upon  the  virulence  of  the  epi- 
demic, the  degree  of  protection  by  vaccination,  and  the  amount 
of  the  eruption.  In  discrete  cases,  it  is  generally  favorable  ; 
in  the  confluent,  grave  ;  in  the  malignant,  almost  hopeless. 

Treatment. — The  prophylactic  treatment  consists  in  vac- 
cination. 

The  Attack. — Isolation.  Every  precaution  must  be  taken  to 
prevent  the  spread  of  the  disease.  The  other  members  of  the 
family  should  be  vaccinated  at  once.  The  room  should  be 
cool  and  well  ventilated.  The  diet  must  be  liquid  or  semi- 
liquid,  and  may  consist  of  milk,  meat  broths,  eggs,  etc.  The  free 
use  of  water,  lemonade,  or  soda-water  should  be  encouraged. 


( 


266  ACUTE   INFECTIOUS  DISEASES. 

The  intense  lumbar  pains  should  be  relieved  by  opium  and  the 
application  of  hot-water  bags.  Gastric  irritability  may  call 
for  bismuth  or  calomel  and  soda.  The  naso-pharynx  should 
be  kept  clean  by  antiseptic  washes  and  sprays,  and  Dobell's 
solution,  dilute  listerine,  or  dilute  peroxide  of  hydrogen  may 
be  used  for  this  purpose.  The  eyes  must  be  kept  clean  by 
being  washed  several  times  a  day  with  a  saturated  solution  of 
boric  acid.  Stimulants  are  often  indicated.  High  fever  may 
be  controlled  by  antipyrin  or  phenacetin,  or  by  the  cold  pack 
or  cold  bath. 

The  prevention  of  Pitting. — The  room  should  be  darkened, 
and  the  exposed  parts  covered  with  cloths  soaked  in  dilute 
carbolic  acid  or  bichloride  of  mercury,  or  with  masks  upon 
which  has  been  spread  some  simple  ointment,  as  one  of  mercury 
or  of  zinc.  Unfortunately,  when  the  lesions  are  deeply  situ- 
ated there  is  no  means  of  preventing  pitting.  The  separation 
of  the  scabs  may  be  facilitated  by  the  use  of  warm  baths. 

VARICELLA. 

(Chicken-pox.) 

Definition. — An  acute  contagious  disease  of  short  duration, 
characterized  by  slight  fever  and  a  discrete  vesicular  eruption, 
which  disappears  in  two  or  three  days  by  desiccation. 

Etiology. — The  disease  occurs  sporadically  and  epidemi- 
cally. It  is  observed  chiefly  in  children,  but  adults  are  not 
exempt.  One  attack  usually  protects  from  others.  It  bears 
no  relation  to  smallpox. 

Period  of  Incubation. — One  to  two  weeks. 

Symptoms. — Slight  fever  and  the  appearance  of  a  vesicular 
eruption  within  the  first  twenty- four  hours.  The  vesicles  ap- 
pear in  crops  over  two  or  three  days  ;  they  are  superficial,  not 
umbilicated,  and  lack  the  red  areola  which  is  seen  around  the 
vesicle  of  variola.  They  rarely  become  pustular,  and  are  only 
occasionally  followed  by  scars.     The  duration  is  about  a  week. 

Diagnosis.  Smallpox. — The  slight  fever ;  the  absence  of 
lumbar  pains ;  the  early  appearance  of  the  eruption  ;  and  the 
absence  of  the  shot-like  feel,  umbilication,  and  red  areola  will 
serve  to  distinguish  varicella  from  smallpox. 


VACCINIA.  267 

Prognosis. — Always  favorable. 

Treatment. — Rest  in  bed.  A  light  diet.  The  application 
of  some  sedative  lotion  or  ointment  to  allay  itching  and  to  pre- 
vent scratching. 

VACCINIA. 

(Vaccination,  Cow-pox.) 

Defiottion. — A  general  disease  with  a  local  manifestation 
resembling  the  pock  of  variola,  and  acquired  by  inoculation 
with  the  virus  of  cow-pox. 

History  and  Object. — The  value  of  vaccination  as  a 
means  of  protection  against  smallpox  was  first  made  known 
to  the  world  in  a  paper  published  by  Edward  Jenner  in  1798. 

Recent  vaccination  gives  almost  complete  immunity  from 
variola ;  the  mortality  of  smallpox  acquired  after  vaccination 
is  almost  inversely  proportionate  to  the  number  of  true  vac- 
cine scars. 

Etiology. — Vaccinia  is  induced  by  inoculating  the  arm 
with  fresh  virus  obtained  from  the  udder  of  a  calf  suffering 
from  cow-pox  (bovine  virus),  or  from  the  vesicle  of  a  patient 
who  has  already  been  vaccinated  (humanized  virus).  The 
former  is  preferable  on  account  of  the  readiness  with  which  the 
fresh  article  can  be  obtained,  and  on  account  of  its  freedom 
from  other  poisons,  like  syphilis. 

Time  of  Performance, — The  first  vaccination  should  be 
made  about  the  third  month,  the  second  at  the  seventh  year, 
and  the  third  at  puberty.  It  should  always  be  repeated  when 
smallpox  is  prevalent. 

'  Performance  of  Vaccination. — The  arm  should  be  ren- 
dered aseptic,  and  the  skin  scratched  with  a  lancet  or  with  the 
ivory  point  containing  the  lymph  until  red  serum  begins  to 
ooze,  when  the  moistened  virus  should  be  carefully  worked  in. 
The  spot  must  be  carefully  protected  from  the  clothes  until 
thoroughly  dry. 

Symptoms. — About  the  second  or  third  day  after  the  opera- 
tion a  papule  surrounded  by  a  red  areola  forms  at  the  seat  of 
inoculation.  In  two  or  three  days  the  papule  is  converted 
into  a  clear  vesicle^  which  is  umbilicated  at  its  summit ;  the 


268  ACUTE  INFECTIOUS   DISEASES. 

surrounding  tissues  are  red,  tender,  and  considerably  infiltrated. 
About  the  seventh  or  eighth  day  the  vesicle  becomes  a  pustule ; 
this  lasts  until  the  twelfth  day,  when  it  dries  up  and  forms  a 
scab,  which  separates  during  the  third  week  and  leaves  behind 
a  pitted  scar.  During  the  course  of  the  eruption  there  are 
slight  fever,  malaise,  restlessness,  and  enlargement  of  the 
axillary  glands. 

Complications. — Erysipelas,  abscess,  and  various  cutaneous 
eruptions.  Syphilis  has  occasionally  been  transmitted  through 
humanized  virus. 

ERYSIPELAS. 

(St.  Anthony's  Fire.) 

Definition.  —  An  acute  contagious  disease  excited  by 
streptococci,  and  characterized  by  a  peculiar  inflammation  of 
the  skin  and  subcutaneous  tissue,  irregular  fever,  and  a  ten- 
dency to  relapse. 

Etiology, — The  disease  is  somewhat  contagious  and  the 
poison  can  be  carried  in  fomites.  Certain. families  and  certain 
individuals  seem  particularly  predisposed.  Puerperal  women 
and  wounded  persons  are  very  susceptible.  Diseases  which 
lower  the  vitality,  especially  Bright's  disease,  predispose.  One 
attack  does  not  protect  against  a  recurrence,  but  rather  favors 
it.  Erysipelas  was  formerly  divided  into  traumatic  and  idio- 
pathic varieties ;  but  the  two  are  identical,  and  it  is  probable 
that  in  those  cases  in  which  there  is  no  conspicuous  wound 
there  is  a  slight  abrasion  through  which  the  poison  gains  ad- 
mittance. 

The  exciting  cause  is  doubtless  the  streptococcus  pyogenes. 

Pathology. — Erysipelas  most  frequently  manifests  itself 
on  the  face.  The  part  is  bright  red  in  color,  swollen,  in- 
durated, and  sharply  circumscribed.  The  various  strata  of  the 
skin  are  infiltrated  with  serum,  and  leucocytes  and  streptococci 
are  found  in  the  lymph-spaces.  In  severe  cases  the  inflam- 
matory products  are  converted  into  pus,  and  abscesses  form. 

Period  of  Incubation. — Three  to  seven  days. 

Symptoms. — Prodromes  are  sometimes  present,  and  consist 
of  slight  fever,  chilliness,  malaise,  tingling  of  the  part  to  be 


ERYSIPELAS.  269 

aifected,  and  sometimes  enlargement  of  neighboring  lymphatic 
glands.  In  many  cases  the  disease  is  ushered  in  suddenly 
with  a  chill,  followed  by  pain  in  the  head  and  limbs  and  a 
high,  irregular  fever.  The  temperature  may  reach  103°  or 
104°  in  twelve  or  twenty- four  hours.  The  pulse  is  full  and 
rapid  ;  the  tongue  is  heavily  coated  ;  the  appetite  is  lost ;  the 
bowels  are  constipated ;  and  the  urine  is  scanty  and  often 
slightly  albuminous. 

Local  Phenomena. — The  inflammation  usually  begins  in  the 
neighborhood  of  the  nose,  and  spreads  upward  and  laterally  over 
the  head  to  the  neck,  where  it  frequently  stops.  The  affected 
part  has  a  crimson  hue;  it  is  swollen  and  tense,  and  frequently 
ends  in  a  sharply-defined  ridge,  beyond  which,  however,  pro- 
jections can  be  felt  advancing  into  the  subcutaneous  tissue. 
The  surface  of  the  inflamed  patch  is  at  first  smooth  and  glazed, 
but  later  it  is  covered  with  minute  vesicles  or  blebs.  The  patient 
complains  of  burning  and  tingling  ;  the  surrounding  parts  are 
extremely  oedematous,  so  that  the  features  may  be  scarcely 
recognizable.  In  four  or  five  days  the  redness  begins  to  fade 
and  the  swelling  to  subside ;  desquamation  follows;  the  general 
symptoms  improve ;  and  the  fever  falls  by  crisis.  The  average^ 
duration  is  from  a  week  to  ten  days.  lielapses  are  extremely  ) 
common. 

Erysipelas  Ambulans. — Sometimes  the  inflammation  disap- 
pears in  one  place  and  reappears  in  another,  and  so  continues 
indefinitely.  In  such  cases  typhoid  symptoms,  such  as  mut- 
tering delirium,  a  brown,  fissured  tongue,  and  subsultus  ten- 
dinum,  develop. 

Complications.  —  Inflammation  of  serous  membranes 
(pericarditis,  pleuritis,  meningitis),  (ledema  of  the  larynx,  ne- 
phritis, hyperpyrexia,  ulcerative  endocarditis,  and  septicemia. 

Diagnosis.  Erythema.  —  The  absence  of  high  fever,  of 
marked  swelling,  and  of  an  abrupt  ridge  will  serve  to  dis- 
tinguish erythema  from  erysipelas. 

Acute  Eczema. — The  swelling  is  less  marked  ;  the  itching  is 
intense  ;  the  swelMng  and  redness  are  not  circumscribed,  but 
shade  gradually  into  healthy  tissue ;  and  there  is  no  fever. 

Prognosis. — In  the  robust  the  prognosis  is  favorable.  In 
the  old,  in  alcoholic  subjects,  and  in  those   suffering   from 


270  ACUTE  INFECTIOUS   DISEASES. 

chronic  nephritis,  the  prognosis  must  be  guarded.    Ambulatory 
erysipelas  may  kill  by  exhaustion. 

Treatment. — Isolation  ;  absolute  rest ;   a  nutritious  diet. 
It  is  well  to  begin  the  treatment  with  a  saline  or  mercurial 
/'laxative.     The  tincture  of  the  chloride  of  iron  seems  to  exert 
,   a  beneficial  influence ;    it  may  be  given  in  doses  of  twenty 
^drops  every  two  hours.     Quinine  (gr.  v  thrice  daily)  is  also 
useful.     When  there  is  much  restlessness  and  insomnia,  bro- 
mide of  potassium,  chloral,  or  opium  may  be  administered. 

Local  Treatment. — One  of  the  following  applications  may  be 
employed :  Cloths  wrung  out  in  a  solution  of  bichloride  of 
mercury  (1-5000),  or  in  a  saturated  solution  of  boric  acid,  or  in 
lead-w'ater  and  laudanum  ;  a  dusting  powder  of  starch  and 
oxide  of  zinc ;  or  an  ointment  of  ichthyol. 

^i  Plumbi  acetatis,  3j  ; 
Tinct.  opii,  f  .^j  ; 
Aquie,  q.  s.  Oj. — M. 
Sig. — Shake  well  and  apply  on  liut. 

Or— 

^   Ichthyol,  §ss ; 
Vaselin.,  ^ij. — M. 
Sig. — Spread  thickly  on  lint  and  apply  to  the  affected  part. 

The  injection  of  antiseptic  remedies  around  the  inflammatory 
patch,  with  the  view  of  preventing  its  spread,  is  very  painful 
and  seldom  efficacious. 


YELLOW  FEVER. 

Definition. — An  acute  infectious  disease,  characterized  by 
jaundice,  epigastric  tenderness,  vomiting,  hemorrhages,  and  a 
febrile  course  consisting  of  two  paroxysms. 

Etiology. — A  hot  climate  and  a  warm  season,  salt  water, 
bad  drainage,  and  overcrowding  favor  the  development  of 
epidemics.  The  disease  is  not  distinctly  contagious ;  the 
poison  probably  undergoes  some  changes  outside  of  the  body, 
and  is  carried  through  the  atmosphere,  clothes,  or  other 
fomites.  The  colored  mce  are  less  susceptible  than  the 
white.     Strangers  in  an  infected  district  are  more  liable  to  be 


YELLOW   FEVEE.  271 

attacked  than  residents.   One  attack  usually  confers  immunity 
from  others. 

Pathology. — The  tissues  are  stained  yellow  by  disin- 
tegrated blood  (hsematogeuous  jaundice).  The  liver  is  pale 
and  is  the  seat  of  extensive  fatty  degeneration.  The  gastric 
mucous  membrane  is  swollen,  congested,  and  frequently  ecchy- 
mosed.  The  spleen  is  not  enlarged.  Tlie  heart  is  pale  and 
flabby.  Thekidneys  are  generally  the  seat  of  parenchymatous 
inflammation. 

Period  of  Incubation. — A  few  hours  to  a  week. 

Symptoms.  First  Stage. — The  disease  begins  with  a  chill, 
followed  by  pain  in  the  head,  back,  and  limbs.  The  tempera- 
ture rises  rapidly  until  it  reaches  its  maximum  (103°-105°). 
The  face  is  flushed,  the  conjunctivae  are  injected,  and  the 
pupils  small ;  the  tongue  is  coated,  the  epigastrium  is  tender, 
the  stomach  is  irritable  and  unretentive ;  the  bowels  are  con- 
stipated ;  and  the  urine  is  scanty  and  albuminous.  This  stage 
lasts  from  a  few  hours  to  several  days,  and  is  followed  by  a 
marked  fall  in  the  temperature  and  an  improvement  in  the^ 
general  symptoms  (stage  of  remission).  At  this  time  con- 
valescence may  begin,  or  the  patient  may  pass  into  the  second 
febrile  paroxysm. 

Second  Stage. — The  fever  rises  to  its  original  height;  the 
skin  becomes  yellow ;  vomiting  is  persistent,  and  the  ejected 
material  may  contain  dark  blood  ("  black  vomit").  Hemor-Y 
rhages  sometimes  occur  from  other  mucous  membranes.  The 
pulse  is  rapid,  though  not  proportionate  to  the  fever.  The 
urine  becomes  very  scanty  and  contains  albumin  and  casts. 
Death  frequently  results  from  exhaustion  or  uraemia,  though 
recovery  may  follow  the  gravest  symptoms. 

Duration. — From  a  few  hours  to  a  week. 

Diagnosis.  Melapsing  Fever. — This  is  distinguished  by 
the  enlargement  of  the  spleen,  the  multiple  paroxysms,  the 
spirilli  in  the  blood,  and  the  absence  of  black  vomit. 

Acute  Yelloio  Ati^ophy  of  the  Liver. — The  early  appearance 
of  jaundice,  the  diminution  in  the  size  of  the  liver,  the  slight 
fever,  the  marked  cerebral  symptoms,  and  the  presence  of 
leucin  and  tyrosin  in  the  urine  will  indicate  acute  yellow 
atrophy. 


272  ACUTE  INFECTIOUS  DISEASES. 

Remittent  Fever. — This  may  be  distinguished  by  the  enlarge- 
ment of  the  spleen,  the  multiple  remissions,  the  presence  in  the 
blood  of  hsematozoa  of  Laveran,  and  by  the  absence  of  black 
vomit. 

Prognosis. — Always  grave.  The  average  mortality  in 
different  epidemics  is  from  twenty  to  seventy  per  cent.  In 
individual  cases,  high  fever,  severe  cerebral  symptoms,  black 
vomit,  and  suppression  of  urine  are  unfavorable  features. 

Treatment. — Absolute  rest.  A  cool,  well- ventilated  room. 
A  liquid  diet.  The  pains  in  the  back  and  limbs  may  be  re- 
lieved by  hot- water  bags  and  the  administration  of  morphine. 
For  the  gastric  irritability  a  mustard  plaster  may  be  applied 
to  the  epigastrium,  and  cracked  ice,  iced  champagne,  carbolic 
acid,  or  small  doses  of  calomel  may  be  given  internally.  Stim- 
ulants are  frequently  indicated.  Quinine  may  be  given  by 
the  rectum.  High  fever  is  best  controlled  by  the  external 
application  of  cold.  The  black  vomit  results  from  blood- 
dyscrasia,  and  while  such  remedies  as  gallic  acid,  Monsel's 
solution,  ergot,  and  turpentine  are  recommended,  they  usually 
prove  useless. 

ACUTE  GENERAI.  TUBERCULOSIS. 

(Acute  Miliary  Tuberculosis.) 

Definition. — An  acute  infectious  disease  excited  by  the 
tubercle  bacillus,  and  characterized  anatomically  by  the 
simultaneous  formation  of  miliary  tubercles  in  many  parts  of 
the  body. 

Etiology. — The  disease  usually  develops  in  early  adult 
life.  Certain  infectious  diseases  like  measles,  whooping-cough, 
and  typhoid  fever  seem  to  predispose.  General  tuberculosis 
is  almost  always  secondary  to  local  tuberculosis — pulmonary 
phthisis  or  a  scrofulous  lymphatic  gland.  The  bacilli  are 
probably  disseminated  by  the  veins. 

Pathology. — All  the  organs  may  be  uniformly  infiltrated 
with  discrete  tubercles,  but  more  commonly  certain  organs, 
like  the  brain  and  lungs,  are  more  affected  than  others. 

Symptoms. — Debility ;  loss  of  flesh  and  strength  ;  fever 
moderately  high (102°-104°),  irregular,  and  marked  by  evening 


ACUTE  GENEEAIi  TUBEKCULOSIS. 


273 


exacerbations  and  morning  remissions ;  cough ;  hurried  respi- 
rations ;  a  brown,  fissured  tongue ;  a  weak,  rapid  pulse ;  en- 
largement of  the  spleen ;  delirium ;  subsultus  tendinum ;  and 
stupor. 

Tubercle  bacilli  are  rarely  found  in  the  expectoration  or  in 
the  blood. 

The  duration  is  from  two  to  four  weeks. 

When  the  lungs  are  chiefly  afl'ected  there  are :  Dyspnoea, 
marked  cough,  muco-purulent  and  bloody  expectoration, 
cyanosis,  sibilant  and  subcrepitant  rales,  and  perliaps  areas 
over  which  bronchial  breathing  is  detected. 

When  the  meninges  ai'e  chiefly  afl'ected  there  are :  Intense 
headache,  convulsive  seizures,  photophobia,  delirium,  facial 
palsies,  stupor,  coma,  and  Cheyne-Stokes  breathing.  Tubercles 
may  be  detected  on  the  retina. 

When  the  intestines  and  peritoneum  are  afl'ected  there  are  : 
Pain,  tenderness,  abdominal  distention,  and  diarrhoea. 

Diagnosis. — The  disease  closely  resembles  typhoid  fever, 
and  there  is  no  doubt  that  the  mortality  of  the  latter  is  en- 
hanced by  included  cases  of  unsuspected  general  tuberculosis. 

The  following  table  will  indicate  the  points  of  distinction  : — 


^ 


Typhoid  Fever. 

Epistaxis  common. 
The  temperature  rises  gradually, 
and  runs  a  regular  course. 

Diarrhoea  is  frequent. 
An  eruption  is  generally  present. 
No  tubercles  on  the  retina. 
Hespirations  are  hurried. 
Facial  palsies  are  rare. 


Acute  General  Tuber- 
culosis. 

Infrequent. 

The    temperature    usually  rises 

abruptly,  and  runs  a  very  ir- 

reguikr  course. 
Infrequent. 
Rarel}''  present. 
Occasionally  detected. 
Still  more  hurried. 
Common. 


Peognosis. — Always  fatal. 

Teeatment. — Palliative.  The  diet  should  consist  of  milk, 
eggs,  and  broths.  Stimulants  are  indicated.  High  fever 
should  be  controlled  by  antipyrin  or  by  the  external  applica- 
tion of  cold. 


18 


274  ACUTE   INFECTIOUS  DISEASES. 

DIPHTHERIA. 

(Diphtheritis,  Malignant  Sore  Throat,  Cynanche  Contagiosa.) 

Definition. — An  acute  contagious  disease  excited  by  the 
Klebs-Lofler  bacillus,  and  characterized  by  moderate  fever, 
glandular  enlargements,  great  prostration,  and  a  fibrinous  exu- 
V  dation  which  is  usually  located  in  the  throat. 

Etiology. — Childhood  (between  three  and  six),  defective 
drainage,  and  catarrhal  conditions  of  the  throat  are  predispos- 
ing factors.  The  poison  is  contained  in  the  secretions  of  the 
throat,  and  may  be  transmitted  through  the  atmosphere  or 
through  fomites.  One  attack  does  not  protect  from  another, 
but  rather  predisposes. 

The  exciting  cause  is  the  Klebs-Lofler  bacillus,  which  is 
found  only  in  the  membranous  exudation.  The  constitutional 
symptoms  result  from  the  poison  generated  by  the  bacillus. 

Pathology. — The  false  membrane  is  usually  found  on  the 
tonsils,  pillars,  and  pharynx,  but  it  may  extend  to  the  mouth, 
larynx,  or  nose.  The  bacillus  coming  in  contact  with  the 
throat  leads  to  the  death  of  the  superficial  cells,  which  ulti- 
mately undergo  coagulation-necrosis.  The  irritation  causes 
a  migration  of  leucocytes,  and  these  undergo  a  similar  necrosis. 
The  membrane  thus  formed  is  of  a  grayish-white  color,  and  is 
more  or  less  adherent,  so  that  when  torn  off  it  leaves  a  raw 
surface.  Sometimes  the  necrosis  extends  to  the  deeper  tissues 
and  causes  widespread  ulceration  and  even  gangrene.  Micro- 
scopically, the  pseudo-membrane  is  composed  of  fibrin,  leuco- 
cytes, bacteria,  and  the  remains  of  epithelial  cells.  The  lym- 
phatic glands  are  considerably  swollen.  The  spleen  is 
engorged.  The  various  organs  and  the  muscles  reveal  fatty 
and  parenchymatous  degeneration.  Examination  of  the  lungs 
frequently  shows  capillary  bronchitis,  catarrhal  pneumonia, 
and  collapse. 

In  some  cases  the  blood  is  dark  and  fluid,  while  in  others 
firm  clots  are  often  found  within  the  heart. 

Types. — Diphtheria  may  be  divided  according  to  the  loca- 
tion of  the  exudate  into :  (1)  Faucial ;  (2)  laryngeal ;  (3) 
nasal ;  (4)  cutaneous.  According  to  the  severity  of  the  attack 
it  may  be  divided  into :  (1)  Mild ;  (2)  grave ;  (3)  malignant. 


DIPHTHERIA.  275 

Period  op  Incubation. — Two  to  ten  days. 

Symptoms.  Faucial  Diplitheria. — The  disease  commonly 
begins  with  chills,  moderate  fever,  malaise,  and  sore  tliroat. 
The  fever,  as  a  rule,  is  not  very  high  (102°-104°)  and  its 
course  is  quite  irregular.  The  pulse  soon  becomes  rapid  and 
feeble ;  the  bowels  are  constipated ;  the  urine  is  scanty  and 
frequently  albuminous;  and  the  prostration  and  pallor  are  often 
out  of  all  proportion  to  the  severity  of  the  febrile  symptoms. 

Local  Phenomena. — The  child  complains  of  difficult  swallow- 
ing ;  the  muscles  of  the  neck  feel  stiif ;  there  is  tenderness 
under  the  jaw ;  the  lymphatic  glands  are  considerably  swollen; 
and  the  fauces  are  covered  with  a  grayish-white  membrane 
which  when  stripped  off  leaves  a  raw  bleeding  surface,  and  is 
soon  followed  by  a  similar  deposit.  The  membrane  may 
spread  to  the  nose  or  larynx. 

The  course  of  the  disease  is  indefinite,  the  average  duration 
being  from  one  to  two  weeks. 

Laryngeal  Diphtheria. — This  is  usually  secondary  by  exten-  \ 
sion  from  the  fauces,  but  it  is  occasionally  primary.  It  is  rec- 
ognized by  hoarseness  or  aphonia,  croupy  cough,  progressive 
dyspnoea,  and  stridulous  breathing.  The  alse  of  the  nose  play  ; 
the  sterno-cleido-mastoids  are  prominent ;  the  supra-sternal 
notch  is  deepened ;  and  the  base  of  the  chest  is  retracted. 
Shreds  of  false  membrane  are  sometimes  expectorated  in  the 
violent  fits  of  coughing.  The  febrile  symptoms  are  usually 
slight.  Death  frequently  results  from  suffocation,  and  recovery 
without  operation  is  unusual. 

Nasal  Diphtheria. — This  is  nearly  always  secondary.  It^ 
is  recognized  by  grave  constitutional  symptoms — high  fever, 
marked  glandular  involvement,  and  great  prostration ;  by  an 
offensive  discharge  from  the  nose ;  by  epistaxis ;  and  by  ex- 
coriation of  the  lips.  The  false  membrane  may  be  detected 
on  inspection. 

Cutaneous  Diphtheria. — This  form  may  be  primary  or 
secondary.  The  constitutional  symptoms  are  similar  to  those 
of  faucial  diphtheria. 

Complications  and  Sequels. — Capillary  bronchitis,  \ 
catarrhal  pneumonia,  pulmonary  collapse,  endocarditis,  heart-  ' 
clot,  nephritis,  and  paralysis.. 


276  ACUTE   INFECTIOUS   DISEASES. 

DiphtheritiG  Paralysis. — This  generally  occurs  during  con- 
valescence and  is  observed  in  about  fifteen  per  cent,  of  all  cases. 
There  is  no  relation  between  the  severitv  of  the  attack  of 
diphtheria  and  the  liability  to  paralysis ;  mild  cases,  which  are 
tliought  to  be  simple  pharyngitis,  are  sometimes  followed  by 
troublesome  paralysis.  The  pharynx  is  the  most  common 
seat,  and  the  palsy  is  recognized  by  difficult  swallowing  and 
the  regurgitation  of  liquids  through  the  nose.  Next  in  fre- 
quency the  eyes  are  involved,  and  strabismus  or  ptosis  de- 
velops. The  heart  may  be  affected,  and  if  sudden  death  does 
not  result,  the  condition  may  be  manifested  by  a  remarkable 
slowing  of  the  pulse.  The  extremities  are  rarely  paralyzed^ 
The  paralysis  is  due  to  a  toxic  neuritis. 

Diagnosis.  Scarlet  Fever. — The  onset  is  more  sudden ; 
the  fever  is  higher ;  the  pulse  more  rapid ;  the  tongue  presents 
a  strawberry  appearance;  a  red  punctiform  rash  appears  on 
the  first  or  second  day ;  and  if  membrane  appears  on  the 
throat,  it  does  not  contain  the  Klebs-Loffler  bacillus. 

Ilembranous  Group. — Laryngeal  diphtheria  is  generally 
secondary  to  faucial  diphtheria ;  it  is  contagious ;  it  is  often 
epidemic ;  it  is  associated  with  greater  constitutional  dis- 
turbance ;  and  it  is  more  apt  to  be  followed  by  sequelae. 

Peognosis. — Always  guarded.  The  mortality  varies  in 
different  epidemics  from  10  to  50  per  cent.  When  the  con- 
stitutional symptoms  are  mild,  and  the  membrane  is  confined 
to  the  fauces  and  shows  little  tendency  to  spread,  the  prognosis 
is  quite  favorable.  The  nasal  and  laryngeal  forms  are  always 
very  grave. 

Treatment. — Isolation.  Absolute  rest.  A  nutritious  diet 
consisting  of  milk,  koumiss,  eggs,  broths,  and  the  like.  Stimu- 
lants are  nearly  always  required,  and  should  be  administered 
as  soon  as  the  pulse  softens.  Tonics  like  iron,  quinine,  and 
mineral  acids  are  useful  when  well  borne.  Of  the  special 
remedies,  mercury  is  the  most  reliable,  and  either  calomel  or 
the  bichloride  may  be  employed.  ' 

^  Hydrarg,  chlor.  mit.,  gr.  j  ; 

Sodii  bicarb.,  gr.  xxiv  ; 

Pulv.  aromat.,  gr.  vj. — M.     (Starr.) 
Et  ft.  in  chart.  No.  xii. 
Sig. — One  powder  every  two  hours. 


DIPHTHERIA.  277 

Iron  may  be  given  with  the  bichloride,  thus : 

R    Hydrarg.  chlor.  corros.,  gr.  j  ; 
Tinct.  ferri  chlor., 
Spt.  vini  rect.,  aa  f^ij ; 
Syr.  limonis, 
Aquae,  aa  f^ij. — M. 
Sig. — Teaspoonful  every  two  hours  for  a  child  of  six  years. 

Although  the  exact  value  of  the  antitoxine  treatment  of 
diphtheria  has  not  yet  been  determined,  the  testimony  in  its 
favor  is  sufficiently  strong  to  warrant  its  employment  in  every 
case.  Welch  of  Baltimore  has  collected  7166  cases  of  diph- 
theria treated  with  antitoxine,  showing  a  mortality  of  only  17.3 
per  cent.  The  serum  treatment,  however,  should  not  displace 
other  measures  of  recognized  value.  The  dose  of  the  serum  is"\ 
from  5  to  20  com.,  according  to  the  strength  of  the  prepara-  ' 
tion  employed  and  the  severity  of  the  attack. 

The  atmosphere  of  the  room  should  be  rendered  moist  by"\ 
slacking  lime,  by  evaporating  water  on  the  stove  or  over  a  j 
spirit-lamp,  or  by  means  of  a  steam  atomizer.  The  addition 
of  turpentine  or  of  oil  of  eucalyptus  to  the  water  is  often  rec- 
ommended. Iodine,  or  an  ointment  of  mercury,  belladonna, 
or  ichthyol,  may  be  applied  to  the  swollen  and  tender  glands. 
The  naso-pharynx  should  be  kept  clean  by  antiseptic  sprays 
or  douches,  and  one  of  the  following  may  be  selected  for  this 
purpose :  Dobell's  solution,  dilute  listerine,  dilute  peroxide  of 
hydrogen,  chlorine- water,  or  corrosive  sublimate  (1  :  2000).  '^ 

Many  solvents  have  been  recommended ;  those  most  com- 
monly employed  are  dilute  lactic  acid,  dilute  hydrochloric  acid 
with  pepsin,  a  solution  of  papayotin,  and  peroxide  of  hydrogen. 
The  last  is  often  useful,  but  it  is  essential  that  it  should  be  fresh. 
When  the  throat  is  not  too  sensitive  it  may  be  employed  undi- 
luted.   Loeffler's  solution  is  very  satisfactory.  The  formula  is — 

R    Menthol.,  3iiss; 
Toluol.,  q.  s.  ad  f^x; 
Solve  et  adde^ 
Alcohol,  absolut.,  f^ij ; 
Liquor,  ferri  chloridi,  f^j. — M. 
Sig. — Apply  with  a  cotton  swab.  ' 

In  laryngeal  diphtheria,  when  these  means  fail,  tracheotomy     ^ 
or  intubation  must  be  resorted  to. 


278  ACUTE   INFECTIOUS   DISEASES. 

WHOOPING-COUGH. 

(Pertussis.) 

Definition. —  An  infectious  disease,  characterized  by 
catarrh  of  the  respiratory  tract  and  peculiar  paroxysms  of 
cough  ending  in  prolonged  crowing  or  whooping  inspiration. 

Etiology. — The  disease  occurs  both  sporadically  and  epi- 
demically. It  is  most  frequently  met  with  in  children,  but 
unprotected  adults  are  not  exempt.  The  disease  is  unquestion- 
ably contagious,  and  the  virus  seems  to  be  associated  with  the 
sputum.     One  attack  protects  from  others. 

Pathology. — No  characteristic  lesions  are  observed  after 
death.  The  poison  excites  an  inflammation  of  the  respiratory 
mucous  membrane,  and  probably  irritates  the  peripheral  fila- 
ments of  the  pneumogastric  nerve,  and  so  causes  the  parox- 
ysmal cough.  In  fatal  cases,  pulmonary  complications  are 
usually  discovered,  such  as  catarrhal  pneumonia,  pulmonary 
collapse,  and  emphysema. 

Symptoms. — There  are  three  stages :  (1)  The  catarrhal 
stage  ;  (2)  the  paroxysmal  stage  ;  and  (3)  the  stage  of  decline. 

Catarrhal  Stage. — The  disease  begins  with  the  symptoms  of 
coryza,  and  bronchial  catarrh — slight  fever,  sneezing,  running 
from  the  nose,  dry  cough,  and  rales.  But  it  does  not  respond 
to  the  ordinary  remedies  for  catarrh,  and  after  lasting  one  or 
two  weeks  passes  into  the  paroxysmal  stage. 

Paroxysmal  Stage. — The  cough  becomes  more  violent  and 
paroxysmal.  During  the  paroxysm  the  face  is  cyanosed,  the 
eyes  are  injected,  and  the  veins  distended.  The  cough  fre- 
quently induces  vomiting,  and,  in  severe  cases,  epistaxis  or 
other  hemorrhages.  The  close  of  the  paroxysm  is  marked  by 
a  long-drawn,  shrill,  whooping  inspiration  due  to  the  spas- 
modic closure  of  the  glottis. 

The  number  of  paroxysms,  or  "  kinks,"  varies  from  ten  or 
twelve  to  forty  or  fifty  in  the  twenty-four  hours.  From  the 
forcible  propulsion  of  the  tongue  against  the  lower  incisors, 
an  ulcer  is  frequently  formed  on  the  frsenum.  The  duration 
of  this  stage  is  three  or  four  weeks. 

Stage  of  Decline. — The  paroxysms  grow  less  frequent  and 


WHOOPING-COUGH.  279 

less  violent  and  finally  cease.  Protracted  cases  are  followed 
by  anaemia  and  prostration. 

Duration. — The  entire  duration  of  the  disease  is  from  a 
few  weeks  to  four  months. 

Complications  and  Sequels. —  Catarrhal  pneumonia, 
pulmonary  collapse,  emphysema,  hemorrhage  into  the  conjunc- 
tiva, ear,  or  brain,  and  convulsions.  Grave  cases  are  some- 
times followed  by  chronic  bronchitis,  tuberculosis,  or  cancrum 
oris. 

Diagnosis. — This  can  rarely  be  made  with  certainty  during 
the  catarrhal  stage.  Later,  the  paroxysmal  cough  ending  in 
vomiting  or  in  whooping  is  absolutely  diagnostic. 

Prognosis.— Guardedly  favorable.  Severe  cases  in  the 
young  and  debilitated  not  infrequently  prove  fatal. 

Treatment. — The  child  should  be  clad  in  flannel  under- 
clothes and  carefully  protected  from  changes  of  temperature. 
During  the  catarrhal  or  febrile  stage  the  patient  should  be  con- 
fined to  bed.  The  diet  should  be  liffht  and  nutritious.  Conn- 
ter-irritants,  like  iodine,  applied  to  the  chest  seem  useful. 
Quinine  is  a  reliable  tonic  and  may  be  employed  throughout 
the  disease.  The  ordinary  expectorant  mixtures  are  valueless. 
Local  applications  to  the  respiratory  mucous  membrane  give 
much  relief.  One  of  the  following  remedies  may  be  inhaled  : 
Creosote  and  chloroform,  dilute  peroxide  of  hydrogen,  or  a 
solution  of  menthol. 

^   Menthol,  gr.  xx  ; 

Petrolat.  liquid.,  f.5J.— M. 
Sig. — Spray  the  naso-pharynx  and  inhale  several  times  a  day. 

In  very  young  children  a  solution  of  menthol  may  be  in- 
haled from  a  cloth  held  under  the  chin.     When  paroxysms  are  "^ 
violent  the  inhalation  of  a  few  drops  of  nitrite  of  amyl  is  de- 
sirable. 

The  following  antispasmodic  remedies  appear  to  lessen  the  \ 
severity  and  the  frequency  of  the  paroxysms:  belladonna,  anti- 
pyrin,  asafoetida,  and  bromoform  (gtt.  i-iv),  potassium  bromide. , 

1^   Sodii  bromidi,  jiss  ; 
Tinct.  belladonnse,  f^j  ; 
Glycerini,  f^ss ; 
Aquse,  q.  s.  ad  fsij.— M. 
Sig. — A  teaspoonful  every  three  or  four  hours. 


280  ACtJTE  INFECTIOUS  DISEASES. 

Or— 

^  Antipyrin,  gr.  xl-lx  ; 
Syr.  tolutan,,  f^J  ; 
Aquse  q.  s.  ad  f|ij. — M. 
Sig. — A  teaspoonful  every  two  or  three  hours. 

ES^FLUENZA. 

(La  Grippe,  Catarrhal  Fever,  Epidemic  Catarrh.) 

/ 

Definition. — An  acute  infectious  disease,  characterized  by 
fever,  extreme  prostration,  pain  in  the  head  and  back,  and 
generally  by  catarrh  of  the  respiratory  or  gastro-intestinal 
tract. 

Etiology. — The  disease  occurs  in  epidemics  which  usually 
have  their  origin  in  Russia,  whence  they  spread  with  wonder- 
ful rapidity  over  both  continents.  The  exciting  cause  is  with- 
out doubt  a  small  bacillus  found  in  the  sputum,  and  first  dis- 
covered by  Pfeiffer  in  1892.  When  prevalent,  no  age  and 
neither  sex  is  exempt.  One  attack  does  not  confer  immunity 
from  others. 

Pathology. — Influenza  does  not  often  kill  save  by  its 
complications.  The  latter  are  most  frequently  associated  with 
the  respiratory  tract,  and  consist  of  capillary  bronchitis,  catar- 
rhal pneumonia,  and  croupous  pneumonia. 

Symptoms. — The  disease  begins  abruptly  with  lassitude, 
malaise,  chilliness,  severe  pain  in  the  head  and  back,  fever 
ranging  between  101°  and  103°,  and  extreme  prostration, 
which  is  out  of  proportion  to  the  fever  and  any  existing  local 
inflammation.  The  catarrhal  symptoms  are  injection  of  the 
eyes,  sneezing,  hoarseness,  and  hard  paroxysmal  cough.  In 
simple  cases  the  temperature  falls  in  two  or  three  days  by 
crisis,  but  complications  not  infrequently  prolong  the  case  for 
several  weeks. 

In  some  cases  the  catarrh  of  the  respiratory  tract  is  the 
chief  feature  ;  in  others  the  gastro-intestinal  tract  is  attacked, 
and  the  symptoms  resemble  cholera  morbus  ;  in  a  third  group 
neuralgic  pains  in  the  head,  back,  and  limbs  are  the  most 
striking  phenomena. 

Complications. — Catarrhal  pneumonia,  croupous  pneu- 
monia, nephritis,  neuritis,  meningitis,  and  insanity. 


MtJMPS.  281 

Diagnosis.  Acute  Bronchitis. — The  fever  is  not  so  high  ; 
there  is  little  or  no  prostration  ;  and  the  pains  in  the  head  and 
back  are  not  nearly  so  marked  as  in  influenza. 

Prognosis. — Uncomplicated  cases  nearly  always  recover. 
In  the  very  old,  and  in  those  debilitated  by  chronic  disease, 
influenza  not  infrequently  proves  fatal. 

Treatment. — Absolute  rest  in  bed  and  a  liquid  diet.  As 
there  is  no  specific,  the  treatment  is  symptomatic.  Quinine  is  a 
useful  stimulant,  and  when  the  stomach  is  irritable  it  may  be 
given  by  the  rectum. 

The  Pains,  —  Hot-water  bags  to  the  head  and  spine ; 
morphia,  or  combinations  of  antipyrin  or  phenacetiu  with 
salol  or  salicin,  thus  : — 

^  Salol, 

Phenacetin,  aa  gss. — M. 
Ft.  in  chart.  Ko.  xii. 
Sig. — One  every  two  hours. 

Or— 

^  Quininse  salicylat.,  gr.  xl; 
Phenacetiu,  ^ss. — M. 
In  20  capsules. 
Sig. — One  every  two  hours. 

Or— 

R   Salicini,  5ij ; 
Phenacetin,  3iss ; 
Olei  gaulther.,  gtt.  v; 
Syr.  acacise,  f^iij. — M. 
Sig. — Teaspoonful  every  hour  or  two. 

Heart-failure  should  be  combated  by  alcohol  and  strychnine. 
Bronchial  catarrh  will  require  the  remedies  indicated  in  simple 
bronchitis.  Sleep  may  be  induced  by  opium,  sulphonal,  or 
bromide  of  potassium. 

MUMPS. 

(Epidemic  Parotitis.) 

Definition. — An  acute  contagious  disease,  characterized 
by  inflammation  of  the  parotid  and  other  salivary  glands. 

Etiology. — The  disease  occurs  sporadically  and  epidemi- 
cally.    It  is  most  frequently  observed  in  young  children,  but 


282  ACtJTE  INFECTIOUS   DISEASES. 

unprotected  adults  are  not  exempt.  Males  are  more  suscep- 
tible than  females.  The  disease  is  highly  contagious,  and  the 
virus  is  probably  contained  in  the  saliva,  but  it  has  not  been 
isolated.     One  attack  confers  immunity  from  others. 

Pathology. — As  the  disease  is  so  seldom  fatal  very  little 
opportunity  is  afforded  for  studying  its  intimate  pathology. 
The  parotid  glands  are  the  seat  of  an  inflammatory  infiltration, 
but  suppuration  does  not  occur.  The  inflammation  shows  a 
marked  tendency  to  leave  the  parotids  and  to  involve  the  testes 
in  the  male,  or  more  rarely  the  mamrase  or  ovaries  in  the  female. 

Period  of  Incubation. — One  to  two  weeks. 

Symptoms. — The  disease  is  ushered  in  with  chilliness,  mal- 
aise, and  moderate  fever  (101°-104°),  followed  by  swelling 
of  one  parotid  gland.  The  swelling  is  observed  below  and 
in  front  of  the  ear,  is  pyriform  in  shape,  and  has  a  doughy 
feel.  The  surrounding  tissues  are  oederaatous,  the  submaxil- 
lary glands  are  likewise  swollen,  and  the  features  may  be  dis- 
torted beyond  recognition.  The  movements  of  the  jaw  are 
restricted  and  painful.  The  saliva  may  be  increased  or  di- 
minished. In  many  cases  the  other  parotid  becomes  similarly 
affected. 

Often  in  the  course  of  the  disease  the  inflammation  suddenly 
subsides  in  the  parotid  gland  and  reappears  in  the  testicle  in 
the  male,  or  in  the  ovary  or  mamma  in  the  female. 

The  duration  of  the  disease  is  usually  five  or  six  days. 

Complications. — Hyperpyrexia,  metastasis  to  the  testicle 
or  ovary,  and  meningitis.  Atrophy  of  the  testicle  rarely 
follows. 

Prognosis.— Favorable. 

Treatment. — Rest  in  bed.  Mild  febrifuges  may  be  given 
internally.  Locally,  lead-water  and  laudanum,  or  some  rube- 
facient liniment  like  the  following,  may  be  employed  : — 

R  Tinct.  iodi, 

Tiuct.  aconit.  rati., 
Tinct.  opii,  aa  f^ij  ; 

Liniment,  chloroform.,  q.  s.  ad  fsiij.— M. 
Sig. — Apply  externally  and  cover  with  cotton-wool. 

The  swollen  testicle  should  be  elevated  and  covered  with 
lint  saturated  with  lead-water  and  laudanum.     If  the  swelling 


CHOLERA.  283 

persists,  an  ointment  of  mercury,  belladonna,  and  ichthyol  will 
be  found  usefid. 

CHOLERA. 

(Asiatic  Cholera,  Epidemic  Cholera,  Malignant  Cholera.) 

Definition. — An  acute  infectious  disease,  generally  epi- 
demic, excited  by  Koch's  comma-bacillus,  and  characterized 
by  vomiting  and  purging  of  a  serous  material,  painful  cramps, 
and  collapse. 

Etiology. — Cholera  has  its  origin  in  India,  and  is  carried 
thence  to  other  parts  of  the  world.  The  exciting  cause  is  the 
comma-bacillus  of  Koch ;  this  usually  has  the  form  of  a 
slightly-ciurved  rod,  but  it  is  occasionally  S-shaped.  The  rice- 
water  evacuations  only  contain  the  bacilli,  which,  under  favor- 
able conditions,  continue  to  grow  outside  of  the  body,  and 
by  gaining  entrance  into  the  healthy  system  propagate  the 
disease.  The  disease  always  spreads  along  the  lines  of  traffic, 
hence  epidemics  nearly  always  begin  at  the  sea-coast  and  ex- 
tend inland.  Cholera  is  slightly,  if  at  all,  contagious ;  like 
typhoid  fever,  the  poison  is  not  carried  through  air,  bat  chiefly 
through  drinking-water.  Laundresses  and  nurses,  from  their 
contact  with  the  evacuations,  readily  acquire  the  disease.  Epi- 
demics are  more  frequent  in  summer  than  in  winter.  No  age 
is  exempt,  but  the  old  are  more  susceptible  than  the  young. 
The  intemperate,  the  debilitated,  and  those  suifering  with  gas- 
tro-intestinal  catarrh  are  especially  predisposed. 

Pathology. — The  body  is  shrivelled ;  movements  of  the 
corpse  are  sometimes  observed ;  rigor  mortis  is  marked  and 
prolonged.  The  tissues  are  dry,  and  the  large  veins  and  right 
side  of  the  heart  contain  thick,  dark  blood.  The  serous  cavi- 
ties are  empty  and  their  surfaces  sticky.  The  intestines  con- 
tain more  or  less  rice-water  fluid,  from  which  cultures  of 
bacilli  can  be  made. 

The  mucous  membrane  has  a  pinkish  color  and  is  often  the 
seat  of  ecchymoses  ;  the  solitary  and  Peyer's  glands  are  swol- 
len. Frequently  extensive  desquamation  of  the  epithelial 
lining  is  observed,  but  this  is  usually  regarded  as  a  post-mor- 


284  ACUTE  INFECTIOUS  DISEASES. 

tem  change.  The  kidneys  reveal  evidences  of  parenchymatous 
inflammation  ;  the  liver  is  the  seat  of  fatty  degeneration. 

As  the  lesions  are  not  sufficient  to  explain  the  clinical  phe- 
nomena, it  has  been  suggested  by  Koch  that  the  bacilli  create 
a  poison  the  absorption  of  which  causes  the  grave  symptoms. 

Period  of  Incubation. — A  few  hours  to  several  days. 

Symptoms. — The  severity  of  the  symptoms  varies  consider- 
ably. In  Avell-marked,  but  favorable,  cases  there  are  three 
stages  :  (1)  Invasion  ;  (2)  algid  or  collapse  ;  (3)  reaction. 

Stage  of  Invasion. — The  disease  usually  begins  with  malaise, 
headache,  diarrhcea,  rumbling  noises  in  the  intestines,  and 
colic.  Frequently  these  symptoms  continue  a  few  days  and 
then  subside ;  such  cases  are  termed  cholerine,  and  are  as  infec- 
tious as  the  fully-developed  disease. 

Stage  of  Collapse. — The  diarrhcea  grows  more  marked ;  the 
evacuations  become  copious,  lose  their  feculent  character,  assume 
a  rice-water  appearance,  and  are  discharged  forcibly  but  with- 
out pain.  Vomiting  soon  develops,  and  the  ejected  material 
resembles  that  passed  by  the  bowel.  Thirst  is  unquenchable. 
Severe  cramps  seize  the  muscles  of  the  calves  of  the  legs,  thighs, 
arms,  and  abdomen.  The  surface  is  cold  and  covered  with  a 
clammy  sweat ;  the  breath  is  cool ;  the  temperature  in  the 
axilla  ranges  from  95°  to  85°,  while  in  the  rectum  it  may  rise  to 
103°  or  more.  The  voice  is  husky  and  finally  reduced  to  a 
whisper ;  the  respirations  are  cj[uickened  ;  the  jjulse  becomes 
more  and  more  feeble  ;  the  body  is  livid  and  shrivelled  ;  the 
hands  resemble  those  of  a  washerwoman ;  the  features  are 
pinched  and  sometimes  distorted  ;  the  eyes  are  frightfully 
sunken.  The  urine  is  more  or  less  suppressed,  and  the  little 
that  is  passed  generally  contains  albumin  and  a  trace  of  sugar. 
Consciousness  is  usually  retained  until  near  the  end,  when  coma 
sets  in. 

The  duration  of  this  stage  is  from  a  few  hours  to  two  days. 

Stage  of  Reaction. — Sometimes,  even  when  death  seems  im- 
minent, the  surface-temperature  begins  to  rise  ;  the  urine  in- 
creases ;  the  pulse  strengthens ;  the  vomiting  ceases ;  the 
evacuations  from  the  bowels  become  less  frequent  and  begin 
to  assume  a  feculent  character,  and  convalescence  is  established. 

Occasionally,  instead  of  convalescence,  symptoms  of  a  typhoid 


CHOLERA.  285 

type  develop,  such  as  moderate  fever,  a  brown,  fissured  tongue, 
subsultus,  muttering  delirium,  and  coma.  This  condition, 
which  is  generally  fatal,  has  been  regarded  as  ursemic. 

Cholera  Sicca. — In  very  violent  cases  collapse  and  death 
may  follow  without  there  having  been  any  evacuation.  After 
death  the  intestines  contain  rice-water  fluid,  which  was  not 
discharged  during  life  probably  on  account  of  paralysis  of  the 
muscular  coat  of  the  bowel. 

Complications  and  Sequelae. — Nephritis,  pneumonia, 
pleurisy,  parotitis,  ulceration  of  the  cornea,  diphtheritic  in- 
flammation of  the  throat  and  fauces,  abscesses,  and  local  gan- 
grene. 

Diagnosis.  Cholera  Morbus. — This  is  always  sporadic; 
the  discharges  are  bilious  in  character ;  a  history  of  dietetic 
errors  and  of  exposure  can  usually  be  obtained ;  and  the  comma- 
bacilli  are  not  detected  in  the  discharges. 

Peognosis. — Generally  unfavorable.  The  mortality  aver- 
ages about  50  per  cent.  In  the  old,  young,  debilitated,  and 
intemperate  it  is  very  fatal.  In  individual  cases,  early  col- 
lapse and  a  low  surface  temperature  are  unfavorable  conditions. 

Treatment.  Piwention. — This  includes  the  isolation  of 
the  sick  ;  absolute  cleanliness  ;  the  disinfection  of  excreta  and 
soiled  bed-clothes ;  the  thorough  boiling  of  all  water  that  is  to 
be  used  for  drinking  purposes ;  the  use  of  a  bland,  unirritating 
diet ;  the  avoidance  of  overwork,  exposure,  and  undue  excite- 
ment ;  and  the  prompt  treatment  of  any  gastro-intestinal  dis- 
turbance that  may  arise. 

The  Attack. — The  violent  vomiting  and  purging  and  the 
cramps  call  for  morphine ;  this  is  best  administered  hypoder- 
mically.  There  are  no  specifics.  A  remedy  frequently  recom- 
mended by  competent  observers  is  sulphuric  acid,  which  may  be 
given  with  laudanum  or  chlorodyne.  Thirst  is  best  assuaged 
by  cracked  ice  ad  libitum  and  acidulated  drinks.  For  the 
vomiting  a  mustard  poultice  may  be  applied  to  the  epigastrium, 
and  iced  champagne,  carbolic  acid,  creosote,  or  dilute  hydro- 
cyanic acid  may  be  given  internally.  For  the  cramps  the 
application  of  hot-water  bags,  warm  fomentations,  or  the  rub- 
bing in  of  warm  oil  may  be  useful ;  when  they  are  very  severe 
a  few  whiffs  of  chloroform  may  be  employed.    When  the  pulse 


286  ACUTE  INFECTIOUS  DISEASES. 

weakens,  stimulants  like  alcohol,  ether,  and  ammonia  should 
be  given  freely. 

Copious  warm-water  enemata  containing  tannic  acid  (1  per 
cent.)  and  laudanum  are  highly  recommended  for  the  purging. 

The  low  temperature  must  be  combated  by  the  use  of  hot 
blankets,  or,  better  still,  by  immersion  in  warm  baths  (98°  to 
104°).  In  collapse,  subcutaneous  or  intravenous  injections  of 
saline  solutions  have  been  highly  recommended.  The  follow- 
ing solution,  which  is  well  spoken  of  by  Fagge,  may  be 
injected  directly  into  the  veins,  or  may  be  allowed  to  flow 
through  a  rubber  tube  attached  to  an  aspirating  cauula,  and 
to  enter  the  subcutaneous  tissue  by  its  own  pressure : — 

1^:^   Sodii  phos.,  gr.  iij  ; 
Sodii  chlorid.,  3j  ; 
Potass,  chlorid.,  gr.  vj  ; 
Sodii  carb. ,  gr.  xx  ; 
Alcohol,  f^ij  ; 
Aquse  destil,,  f^xx.— M. 

The  fluid  should  be  warm,  and  the  injection  should  be  con- 
tinued until  the  pulse  strengthens ;  as  much  as  eighty  ounces 
may  be  introduced  at  one  time. 

The  diet  should  consist  of  the  following  :  Light  broths,  milk 
with  carbonated  water,  koumiss,  wine-whey,  thin  gruels,  and 
frozen  blocks  of  beef-tea. 

TETANUS. 

(Lockja-yy.) 

Definition. — An  acute  infectious  disease  excited  by  a 
special  bacillus,  and  characterized  by  painful  tonic  spasms  of 
the  voluntary  muscles. 

Etiology. — In  the  tropics,  especially  in  the  colored  race, 
the  disease  often  arises  idiopathically.  In  temperate  climates 
the  poison  nearly  always  gains  entrance  through  a  wound. 
Lacerated  and  punctured  wounds,  frost-bites,  and  burns  are 
especially  liable  to  become  infected.  Exposure  to  cold  and 
wet  after  traumatism  seems  to  predispose.  Since  the  intro- 
duction of  antiseptic  surgery  tetanus  is  less  common  than 
formerly. 


TETANUS.  287 

The  exciting  cause  is  a- special  microorganism — the  tetanus 
bacillus. 

Pathology. — Congestion  of  the  spinal  cord  and  of  the 
nerves  leading  to  the  wound. 

Symptoms. — The  disease  begins  with  a  feeling  of  rigidity 
in  the  muscles  of  the  neck  and  lower  jaw ;  bj  degrees  the 
muscles  of  the  back,  abdomen,  and  lower  extremities  are 
similarly  involved.  The  brow  is  Avrinkled,  the  corners  of  the 
mouth  are  drawn  upwards  (^risiis  sardonicus),  the  jaws  are 
tightly  closed  (trismus),  and  the  body  becomes  arched,  the 
patient  resting  on  his  head  and  heels  [opisthotonos).  There  is 
extreme  hypersesthesia,  so  that  the  slightest  touch  causes  a 
violent  exacerbation  of  the  spasm,  which  is  attended  by  ex- 
cruciating pain.  If  the  respiratory  muscles  are  involved,  there 
is  intense  dyspnoea.  The  temperature  usually  remains  normal  "\ 
until  just  before  death,  when  it  may  rise  to  107°  or  more.  ' 
The  mind  is  clear  to  the  end.  The  duration  is  from  a  few 
days  to  several  weeks. 

Diagnosis.  Strychnia-poisoning. — The  history  of  the  case, 
the  complete  relaxation  between  the  spasms,  and  the  late  in- 
volvement of  the  jaw  will  indicate  strychnia-poisoning. 

Tetany. — The  history,  the  paroxysmal  character  of  the 
spasms,  the  involvement  of  the  hands,  and  the  escape  of  the 
trunk  and  jaw  will  serve  to  distinguish  tetany  from  tetanus. 

Prognosis. — Unfavorable.  Slight  involvement  of  the 
muscles  of  the  trunk,  absence  of  fever,  and  a  slow  course  are 
favorable  features. 

Treatment. — The  wound  should  be  rendered  aseptic. 
Morphine  is  indicated  for  the  relief  of  the  pain.  Bromide  of 
potassium  (3j  every  two  hours)  and  chloral  should  be  used  to 
control  the  convulsions.  When  asphyxia  is  threatened  by  the 
violence  of  the  spasm,  inhalations  of  chloroform  should  be 
employed.  When  the  patient  is  unable  to  swallow,  he  must 
be  fed  through  the  nose  or    by  the  rectum. 

Antitoxines  derived  from  the  blood  of  animals  which  have  \ 
been  rendered  immune  will  doubtless  prove  to  be  a  valuable 
addition  to  the  therapy  of  this  dread  disease. 


288  ACUTE  INFECTIOUS  DISEASES. 

DENGUE. 

(Break-bone  Fever,  Dandy  Fever.) 

Definition. — An  acute  infectious  disease,  characterized  bj 
pains  in  the  muscles  and  joints,  a  variable  rash,  and  a  febrile 
course  of  two  paroxysms. 

Etiology. — Dengue  is  confined  almost  entirely  to  hot  cli- 
mates. Although  it  occurs  in  epidemics,  its  contagiousness  is 
still  a  matter  of  dispute. 

Period  of  Incubation. — Three  to  five  days. 

Symptoms. — The  invasion  is  usually  sudden  and  is  attended 
with  lassitude,  chilliness,  headache,  intense  pain  in  the  muscles 
and  joints,  and  high  fever.  The  latter  rises  rapidly  and  often 
reaches  a  maximum  of  104°-105°  in  a  few  hours.  The  pulse 
is  rapid  and  full ;  the  respirations  are  accelerated;  the  mind  is 
often  delirious ;  the  urine  is  scanty  ;  the  joints  are  swollen  and 
stiff.  In  two  or  three  days  the  temperature  falls,  and  an 
afebrile  period  follows  in  which  the  patient  is  free  from  pain, 
but  is  profoundly  prostrated.  During  the  remission  a  roseo- 
lar  or  a  diffuse  erythematous  rash  generally  appears ;  this  lasts 
two  or  three  days  and  is  followed  by  slight  desquamation. 
Shortly  after  the  subsidence  of  the  rash,  the  fever  and  pains 
again  return,  and  persist  for  two  or  three  days  when  conva- 
lescence begins. 

Diagnosis. — Acute  rheumatism.  The  prevalence  of  an 
epidemic,  and  the  distinct  remission  will  usually  render  the 
diagnosis  apparent. 

Prognosis. — Favorable. 

Treatment. — There  is  no  specific  remedy.  High  fever 
should  be  controlled  by  the  external  application  of  cold  or  by 
the  use  of  antipyrin.  Morphine,  salol,  antipyrin,  or  pheuacetin 
may  be  employed  to  relieve  pain.  Prostration  must  be  com- 
bated by  stimulants,  like  alcohol,  quinine,  and  strychnine. 

HYDROPHOBIA. 

(Rabies.) 

Definition. — A  disease  of  dogs  and  kindred  animals,  com- 
municated to  man  by  direct  inoculation,  and  characterized  by 


HYDROPHOBIA.  289 

slight  fever,  painful  spasm  of  the  muscles  of  the  throat,  deli- 
rium, paralysis,  and  coma. 

Etiology. — Rabies  invariably  results  from  the  bite  of  a 
rabid  animal,  generally  a  dog.  In  the  animal  the  disease  is 
characterized  by  depression  of  spirits,  loss  of  appetite,  followed 
by  excitement,  aimless  roving,  a  morbid  desire  to  bite,  and 
finally  by  paralysis  and  death  from  exhaustion.  The  poison  is 
contained  in  the  saliva  and  blood.  Pasteur  has  induced  the 
disease  by  direct  inoculation,  and  has  found  that  the  virus  is 
attenuated  by  passing  several  times  through  the  monkey. 
Bites  on  the  face  and  on  exposed  parts  are  more  liable  to  be 
followed  by  infection. 

Pathology. — Intense  congestion  of  the  spinal  cord  and  of 
the  respiratory  mucous  membrane. 

Period  of  IisicuBATioisr. — Six  weeks  to  six  months.") 

Symptoms.  First  Stage. — Depression  of  spirits,  restless- 
ness, slight  difficulty  in  swallowing,  and  pain  in  the  wound  or 
cicatrix.     In  a  few  days  the  stage  of  excitement  begins. 

Second  Stage. — Clonic  convulsions,  involving  especially  the 
muscles  of  the  throat,  occurring  spontaneously  or  excited  by 
drinking  or  by  the  sight  of  water ;  hypersesthesia,  delirium, 
moderate  fever,  and  salivation.  This  stage  lasts  a  few  days, 
and  is  followed  by  paralysis. 

Third  Stage. — The  pulse  weakens  ;  the  convulsions  cease  ; 
the  patient  lies  motionless ;  the  mind  becomes  clouded  ;  and 
death  results  in  twelve  or  twenty-four  hours  from  exhaustion. 

Diagnosis. — Hysteria  in   persons  who  have    been   bitten^ 
may  simulate  hydrophobia.     Such  persons  often  bark,  try  to 
bite,  and  manifest  other  symptoms  which  are  not  noted  in  hy- 
drophobia. 

Prognosis. — Invariably  fatal. 

Treatment.     Prophylaxis.  —  Suspicious   bites   should   be 
thoroughly  disinfected  and  cauterized  by  the  hot  iron  or  caus- 
tic potash,  after  which  the  patient  should  be  sent  to  an  institute 
where   inoculation   may    be    practised  after   the   method    of  I 
Pasteur. 

Tlie  Attack. — Palliative.  For  the  convulsive  seizures  mor- 
phine may  be  employed  hypodermically,  and  chloroform  by  in- 
halation.   The  strength  may  be  sustained  by  rectal  alimentation, 

19 


CONSTITUTIONAL  DISEASES. 


RHEUMATIC  FEVER. 

(Acute  Articular  Rheumatism,   Inflammatory  Rheumatism.) 

Definition. — An  acute  general  disease,  characterized  by 
irregular  fever,  acid  sweats,  inflammation  of  the  joints,  and  a 
marked  tendency  to  involv^e  the  heart. 

Etiology. — Heredity,  temperate  zone,  occupations  which 
necessitate  exposure  to  cold  and  wet,  early  life  (15-40),  and 
one  attack  are  predisposing  factors.  The  disease  is  usually 
precipitated  by  sudden  chilling  of  the  body. 

The  exciting  cause  is  still  unknown.  Some  regard  it  as  a 
neurosis ;  others  believe  it  to  be  infectious,  and  classify  it  with 
pneumonia,  erysipelas,  and  similar  diseases  ;  while  still  others 
attribute  it  to  deranged  metabolism.  According  to  the  last 
theory,  the  nitrogenous  products,  instead  of  being  converted  into 
urea,  are  transformed  into  lactic  acid,  uric  acid,  and  other  allied 
substances,  and  these  deleterious  agents  are  responsible  for  the 
symptoms. 

Pathology. — The  ligaments  and  the  synovial  membrane 
and  its  fringes  are  congested  and  swollen.  The  synovial  sac  is 
filled  with  a  turbid  fluid.  The  cartilages  are  roughened  and 
occasionally  ulcerated.  Generally  the  process  ends  in  resolu- 
tion ;  sometimes  the  surrounding  tissues  become  infiltrated 
with  inflammatory  lymph,  and  false  anchylosis  results  ;  rarely, 
suppuration  of  the  joint  follows.  Sometimes  small, subcuta- 
neous, fibrous  nodules  are  found  near  the  joints  and  large  ten- 
dons. The  blood  shows  an  excess  of  fibrin  and  a  considerable 
diminution  of  the  red  corpuscles.  Fibrinous  clots  are  often 
found  in  the  heart  and  great  bloodvessels. 

Secondary  inflammations  are  frequently  discovered,  such  as 
endocarditis,  pericarditis,  pleurisy,  or  pneumonia. 
(  290 ) 


KHEUMATIC   FEVEE.  291 

Symptoms. — The  symptoms  vary  much  in  their  severity. 
The  disease  usually  begins  abruptly,  or  more  rarely  follows  such 
prodromes  as  malaise,  chilliness,  and  sore  throat.  The  large 
joints,  especially  the  symmetrical  ones,  are  usually  aif'ected  ; 
they  are  slightly  reddened,  swollen,  exquisitely  painful,  and 
tender  to  the  touch.  The  inflammation  shows  a  marked  ten- 
dency not  only  to  spread  from  joint  to  joint,  but  to  disappear 
abruptly  in  one  while  it  attacks  another.  The  joints  most\ 
commonly  involved  are  the  knees,  elbows,  ankles,  and  wrist ; 
but  no  joint  is  exempt.  In  severe  cases  the  muscles  are  pain- 
ful, tender,  and  sometimes  rigid.  The  fever  rises  rapidly  to  a 
moderate  height  (102°-103°),  and  is  indefinite  in  its  duration 
and  extremely  irregular  in  its  course.  Perspiration  is  often" 
copious,  has  a  peculiar  sour  smell  and  an  acid  reaction.  The 
urine  is  scanty,  high-colored,  and  on  standing  throws  down  an 
abundant  sediment  of  urates  and  uric  acid.  The  tongue  is 
heavily  coated  ;  the  appetite  is  lost ;  and  the  bowels  are  con- 
stipated. The  face  is  at  first  flushed,  but  as  the  disease 
advances  it  becomes  decidedly  pale  from  anaemia. 

The  duration  is  indefinite,  varying  from  a  few  days  to 
several  weeks. 

Complications. — Endocarditis  (in  40  per  cent,  of  all  cases); 
pleurisy;  pericarditis;  pneumonia;  hyperpyrexia  (106°-109°), 
which  is  often  associated  with  maniacal  delirium;  chorea;  iritis; 
meningitis;  and  certain  cutaneous  phenomena,  such  as  urticaria, 
purpura,  erythema  nodosum,  and  subcutaneous  fibrous  nodules. 

Diagnosis.     Septic  Arthritis. — This  may  be  recognized  by\ 
its  association  with  some  other  septic  process  and  by  the  special 
tendency  of  the  inflammation  to  end  in  suppuration,  which  is  a 
very  rare  termination  of  rheumatic  fever. 

Gonorrhoeal  Rheumatism. — This  may  be  recognized  by  the 
history,  by  its  obstinate  character,  and  by  its  tendency  to  in- 
volve, not  only  large  joints,  but  certain  small  joints  which  are 
rarely  affected  in  rheumatic  fever,  like  the  sterno-clavicular, 
temporo-maxillary,  and  sacro-iliac. 

Rheumatoid  Arthritis. — This  begins  in  the  small  joints, 
attacks  one  after  another,  leads  to  permanent  deformity,  is  not 
associated  with  fever  and  sweats,  and  shows  no  tendency  to 
involve  the  heart. 


292  CONSTITUTIONAL  DISEASES. 

Gout. — This  occurs  later  in  life,  usually  involves  the  great 
toe,  and  lacks  high  fever,  acid  sweats,  and  the  tendency  to 
heart  complications. 

Prognosis. — Guarded.  Most  cases  end  in  recovery ;  some 
in  chronic  rheumatism ;  a  very  small  number  die  of 
exhaustion,  or  some  complication,  such  as  hyperpyrexia.  It 
is  very  prone  to  relapse  and  to  recur.  The  most  frequent 
complication  is  endocarditis  ;  this  may  never  give  rise  to 
trouble,  but  frequently  it  leads  to  slow  thickening  or  retrac- 
tion of  the  valves  and  to  all  the  phenomena  of  chronic  heart 
disease. 

Treatment. — Absolute  rest  in  a  room  well-ventilated  but 
free  from  draft ;  the  patient  should  lie  between  blankets. 
The  diet  should  consist  mainly  of  milk  and  light  broths  ;  meat 
should  be  interdicted.  The  free  use  of  lemonade  or  mineral 
waters  should  be  encouraged.  Opium,  phenacetin,  or  antipy- 
rin  may  be  required  to  relieve  the  pain. 

Two  remedies  have  considerable  power  in  controlling  the 
disease  :  salicyl  compounds,  and  alkalies,  like  the  salts  of  potas- 
sium ;  these  remedies  may  be  given  separately  or  in  combina- 
tion. The  salicylates  relieve  the  pain,  but  do  not  prevent  re- 
lapses or  cardiac  complications  ;  the  alkalies  apparently  lessen 
the  tendency  to  endocarditis. 

Salicylic  acid  (gr.  x  in  capsules)  or  salicylate  of  sodium  (gr. 
x-xx)  may  be  given  every  two  hours.  Large  doses  may  excite 
nausea  and  ringing  in  the  ears. 

^  Sodii  salicylat.,  ^ij  ; 

Tinct.  cardamom,  comp.,  fjiv; 
Glycerin.,  f^ij  ; 
Aquse  q.  s.  ad  fgiv. — M. 
Sig. — A  tablespoonful  every  two  hours. 

The  oil  of  gaultheria  (n\^x  every  two  hours)  is  another  sali- 
cyl compound  of  decided  value.     If  alkalies   are  employed, 
f  half  a  drachm  of  bicarbonate  of  potassium  may  be  administered 
every  two   hours  until    the  urine    becomes  distinctly  alkaline. 
It  is  a  good  plan  to  combine  alkalies  with  salicylates,  thus  : — 


RHEUMATIC  FEVER.  293 

^   Sodii  salicylat.,  ^ij  ; 
Potass,  bicarb.,  3iij  ; 
Glycerini, 

TiDct.  cardamom,  comp.,  aa  ^ss  ; 
Aquee  q.  s.  ad  f5v. — M. 
Sig. — A  tablespoonful  every  two  hours. 

When  there  is  much  ansemia  Basham's  mixture  (3j-Iss) 
may  be  given  with  the  salicylate,  or  the  following  combina- 
tion may  be  employed  : — 

]^  Acid,  salicylic,  jss  ; 
Ferri  pyrophosphat.,  ^j; 
Sodii  phospbatis,  gx ; 
Aquse,  fgvj.— M.     (Peabody.) 
Sig. — Tablespoonful  every  two  hours  until  relieved. 

Local  Treatme7it. — The  joints  may  be  painted  with  iodine 
and  wrapped  in  cotton-wool.  In  severe  cases  small  blisters 
are  of  great  utility.  Chloroform  liniment,  aconite  liniment, 
lead-water  and  laudanum  are  also  efficient  remedies.  The 
salicyl  preparations,  when  applied  locally,  often  relieve  the 
pain  better  than  any  other  remedy.  The  following  mixture 
may  be  employed  : — 

IJL  ^ther., 
Alcohol., 

Ol.  gaultherise,  aa  ^j  ; 
Lin.  saponis  q.  s.  ad  Oj. — M. 
Sig. — Apply  locally. 

Or— 

^  01.  gaultherise, 

01.  olivae, 

Lin.  saponis, 

Tinct.  aconit., 

Tinct.  opii,  aa  f^iss. — M. 
Ft.  liniment. 
Sig. — Apply  locally. 

Sometimes  ichthyol  proves  serviceable. 

^   Ichthyol,  3;ij  ; 

Ext.  belladonnse,  ^j  ; 
"Vaselin.,  ^ij. — M. 
Sig. — Apply  locally. 

Hypeyyyrexia.  —  This  should  be  treated  promptly  by  the 
cold  pack  or  the  cold  bath. 


294 


CONSTITUTIONAIi  DISEASES. 


Etidocarditis. — This  usually  causes  no  subjective  disturbance 
and  the  general  treatment  need  not  be  modified.  When  the 
pulse  is  rapid  and  irregular,  and  the  patient  complains  of 
precordial  distress,  a  blister  may  be  applied  and  digitalis  may 
be  given  internally.  Absorbents  like  the  iodide  of  potassium 
are  useless.  Convalescence  should  be  protracted  so  as  to  allow 
time  for  perfect  compensation. 

Convalescence. — Such  tonics  as  iron,  quinine,  and  stryclinine 
are  useful  during  this  period. 

CHRONIC  RHEUIVIATISM. 

Etiology. — It  usually  begins  as  a  chronic  affection.  He- 
redity, advanced  years,  and  habitual  exposure  to  cold  and  wet 
are  the  predisposing  factors.  It  rarely  results  from  an  acute 
attack. 

Pathology. — The  fibrous  structures  around  the  joint  are 
greatly  thickened,  so  that  in  long-standing  cases  the  movements 
are  restricted ;  the  neighboring  muscles  are  wasted  from  disuse; 
\  and  the  nerves  often  reveal  evidences  of  neuritis. 

Symptoms. — Pain,  stiffness,  deformity,  and  creaking  of  the 
joints  are  the  usual  phenomena.  Several  joints  are  commonly 
affected,  and  the  disease  shows  no  predilection  for  any  par- 
ticular joint.  The  symptoms  grow  worse  on  the  approach  of 
stormy  weather,  and  at  such  times  exacerbations  are  liable  to 
occur,  in  which  the  joints  become  swollen  and  tender.  The 
duration  is  indefinite. 

Complications. — Arterial  degeneration  and  chronic  endo- 
carditis. 

Prognosis. — Generally  unfavorable.  Much  relief  may  fol- 
low persistent  and  judicious  treatment,  but  perfect  cure  is 
rarely  attainable. 

Treatment. — Especial  attention  should  be  given  to  the 
hygiene,  particularly  as  regards  diet,  bathing,  clothing,  exer- 
cise, and  occupation.  A  change  of  residence  to  a  dry,  warm, 
and  equable  climate  may  effect  a  cure.  The  tone  of  the  sys- 
tem is  often  reduced ;  hence,  tonics  like  iron,  quinine,  strych- 
nine, and  arsenic  may  be  of  considerable  value.  The  special 
f  remedies  are  iodide  of  potassium,  guaiac,  sulphur,  salicylic  acid, 


CHRONIC  RHEUMATISM.  295 

and  alkalies  like  the  salts  of  potassium  and  lithium.     Mineral 
waters  are  sometimes  useful. 

^  Liq.  potass,  arsenitis,  f  gij  ; 
Potass,  iodid.,  gij  ; 
Syr.  simp.,  fgiij.— M.     (Da  CoSTA.) 
Sig.— A  teaspoonful  three  times  a  day  in  water  after  meals. 


OTHER  MANIFESTATIONS  OF  RHEUMATISM 

Muscular  Rheumatism  {myalgia,  wyodynia). — An  affection 
of  the  voluntary  muscles,  characterized  by  pain,  tenderness,  and 
rigidity. 

Types. — Different  names  have  been  applied  according  to  n^ 
the  location,  namely :  Torticollis,  or  wry-neck,  when  it  in-  | 
volves  the  sterno-cleido-mastoid  muscles ;  lumbago,  when  it  j 
involves  the  lumbar  muscles ;  pleurodynia,  when  it  involves  .' 
the  intercostals ;  and  cephalodynia,  when  it  involves  the  oc- 
cipito-frontalis. 

Etiology — The  gouty  or  rheumatic  diathesis  is  a  predis- 
posing cause.  Exposure  to  cold  and  wet  or  muscular  strain 
usually  excites  it. 

Symptoms. — Pain  is  the  chief  symptom;  it  is  made  worsen 
by  use  of  the  muscles,  and  is  associated  with  tenderness  which 
is  especially  marked  at  the  tendinous  origins  and  insertions  of 
the  muscles.     Sometimes  the  muscles  are  contracted  and  rigid  ; 
this  is  particularly  the  case  in  torticollis,  or  wry-neck. 

Torticollis. — The  head  is  fixed  and  inclined  to  one  side; 
every  effort  to  turn  it  is  attended  with  sharp  pain. 

Lumbago. — There  is  a  dull,  aching  pain  across  the  loins. 
Turning  the  body  or  rising  from  the  sitting  posture  causes  an 
exacerbation,  which  is  sometimes  so  severe  that  the  patient 
cries  out.  Care  must  be  taken  to  distinguish  it  from  renal  cal- 
culus, Pott's  disease,  aneurism,  perinephritis,  and  uterine  or 
ovarian  disease. 

Pleurodynia. — The  pain  is  felt  in  the  side,  and  is  increased  by 
deep  breathing,  coughing,  or  twisting  the  body;  the  respirations 
are  restricted  on  the  affected  side.  There  is  diffuse  tenderness 
to  the  touch.  The  absence  of  fever  and  of  physical  signs  will 
serve  to  distinguish  it  from  pleurisy. 


296  CONSTITUTIONAL  DISEASES. 

The  absence  of  tender  spots  where  the  nerves  make  their 
exit  from  the  muscular  coverings,  the  fact  that  the  pain  does 
not  follow  closely  the  distribution  of  the  nerves,  and  that  the 
pain  is  increased  by  movement,  will  serve  to  distinguish  pleuro- 
dynia from  intercostal  neuralgia. 

Cejjhalodynia. — This  is  characterized  by  a  superficial  head 
pain  which  is  increased  by  moving  the  scalp  and  which  is 
associated  with  tenderness  on  pressure, 

PnoGNOSis. — Favorable  under  judicious  and  persistent 
treatment. 

TREATMENT. — The  affected  muscles  should  be  put  at  rest. 
In  pleurodynia  this  is  best  accomplished  by  strapping  the 
affected  side  as  for  fracture  of  the  ribs.  In  lumbago  a  large 
piece  of  adhesive  plaster  may  be  applied  from  the  floating  ribs 
to  the  iliac  crests.  In  mild  cases  the  thorough  application  of 
liniments  containing  chloroform,  aconite,  belladonna,  and  lauda- 
num will  be  all  that  is  required.  In  other  cases  prompt  relief 
often  follows  the  injection  of  morphine  (gr.  ^  with  atropine  (gr. 
Y25),  directly  iuto  the  muscle.  The  continued  current  is  some- 
times useful.  The  introduction  of  needles,  three  or  four  inches 
long,  deeply  into  the  muscles  (acupuncture)  occasionally  gives 
brilliant  results. 

Internally,  in  acute  cases,  chloride  of  ammonium  (gr.  x  four 
times  daily)  may  prove  efficient.  In  chronic  cases,  iodide  of 
potassium,  guaiac,  colchicum,  and  the  salts  of  lithium  are  the 
remedies  usually  employed.  Gelsemium  pushed  to  its  physio- 
logical limit  has  been  successful  when  other  remedies  have 
failed. 

Neural  Manifestation. — Eheumatism  appears  to  be  a  fre- 
quent cause  of  neuritis. 

Rheumatic  Affections  of  Mucous  Membranes. — It  must  be 
borne  in  mind  that  pharyngitis,  tonsillitis,  laryngitis,  and 
bronchitis  are  sometimes  dependent  upon  a  rheumatic  diathesis. 

Rheumatic  Affections  of  Serous  Membranes. — Endocar- 
ditis, pericarditis,  pleuritis,  iritis,  and  peritonitis  may  be  excited 
by  rheumatism. 

Cutaneous  Manifestations.— Purpura,  urticaria,  and  ery- 
thema nodosum  are  sometimes  associated  with  rheumatism. 


GOUT.  297 

GOUT. 

(Podagra.) 

Definition. — A  general  disease,  characterized  by  varied 
constitutional  disturbances,  the  presence  of  uric  acid  in  the 
blood,  the  deposition  of  urate  of  soda  in  the  fibrous  structures 
of  the  joints,  and  recurrent  attacks  of  acute  arthritis. 

Etiology. — Middle  and  advanced  life,  male  sex,  heredity, 
a  rich  diet  and  the  indulgence  in  liquors  (especially  malt 
liquors  and  strong  wines),  want  of  exercise,  and  working  in 
lead  are  general  predisposing  factors. 

Pathology.— The  blood  contains  uric  acid,  and  the  fibrous 
structures  of  the  joint  are  the  seat  of  a  deposit  of  urate  of  soda. 
It  is  probable  that  from  defective  nerve-power  the  tissues 
generally  are  unable  to  perfect  the  metabolism  of  nitrogenous 
products  into  urea,  and  that  uric  acid  and  allied  substances  are 
thus  formed.  According  to  Ebstein,  the  uric  acid  excites  a 
necrosis  of  the  cartilages,  whereupon  the  urates  are  crystallized 
out  and  deposited. 

The  cartilages  lose  their  pearly  appearance  and  become 
lustreless  and  infiltrated  with  salts ;  similar  opacities  appear  in 
the  synovial  membrane;  later  rounded  masses  of  urate  of  soda 
(tophi),  varying  in  size  from  a  pea  to  a  marble,  accumulate  in 
the  tissues  surrounding  the  joint  and  may  ulcerate  through  the 
skin  and  be  discharged.  The  fibrous  structures  become  brit- 
tle and  undergo  destructive  changes.  The  joint  becomes 
irregularly  enlarged,  stiif,  and  finally  anchylosed.  The  meta- 
tarso -phalangeal  joint  of  the  great  toe,  especially  the  right  one, 
is  first  affected,  but  soon  other  small  joints  are  involved. 
Gouty  deposits  are  sometimes  found  along  the  tendons,  beneath 
the  peritoneum,  in  the  perichondrium  of  the  ear,  and  in  the 
tarsal  cartilages. 

The  kidneys  are  generally  the  seat  of  a  chronic  interstitial 
inflammation,  and  section  frequently  reveals  a  deposit  of 
urates  at  the  apices  of  the  pyramids  (gouty  kidney).  The 
arteries  are  sclerosed  and  the  left  side  of  the  heart  is  hypertro- 
phied. 

Symptoms.  Acute  Gout. — Such  prodromes  as  restlessness, 
insomnia,  moroseness,  and  irritability  of  temper  may  precede  the 


298  CONSTITUTIONAL   DISEASES. 

attack.  The  arthritic  phenomena  usually  appear  suddenly  i  n  the 
early  morning  hours  and  are  characterized  by  pain  and  swell- 
ing in  the  ball  of  the  great  toe.  The  affected  joint  is  exqui- 
sitely painful  and  tender,  so  that  the  slightest  pressure  cannot 
be  borne ;  it  is  of  a  reddish-purple  color ;  its  surface  is  glazed; 
and  the  neighboring  veins  are  full  and  distinct. 

The  constitutional  symptoms  are  restlessness,  chilliness, 
moderate  fever,  perspiration,  constipation,  and  scanty  high- 
colored  urine,  which  contains,  during  the  paroxysm,  less  urates 
than  in  health.  Towards  daylight  the  symptoms  abate  and 
the  patient  falls  to  sleep.  During  the  day  he  is  comparatively 
comfortable,  but  there  are  severe  exacerbations  for  several 
successive  nights.  At  first  the  attacks  may  be  a  year  ajmrt, 
but  as  they  multiply  the  interval  grows  less,  until  finally  the 
patient  is  seldom  entirely  free  from  suffering. 

Retrocedent  Gout. — This  term  is  applied  to  a  condition  in 
which  the  arthritic  phenomena  suddenly  subside  and  grave 
gastric,  cardiac,  or  cerebral  symptoms  follow. 

Chronic  Gout. — The  joints  are  affected  one  by  one,  and 
become  stiff,  irregularly  enlarged,  and  deformed.  Chalk- 
stones,  or  tophi,  sometimes  ulcerate  their  way  through  the 
skin  and  are  discharged.  Similar  deposits  are  frequently 
found  along  the  tendons  and  in  the  helix  of  the  ear.  The 
constitutional  symptoms  vary  much  in  severity  and  in  char- 
acter. 

Nervous  Phenomena. — Vertigo,  headache,  insomnia,  irrita- 
bility of  temper,  and  hypochondriasis. 

Gastro-intestinal  Phenomena. — Perverted  appetite,, dyspepsia, 
constipation,  and  a  tendency  to  hemorrhoids. 

Urinary  Phenomena. — The  urine  is  at  first  scanty,  high- 
colored,  and  throws  down  an  abundant  brick-dust  sediment ; 
but  ultimately  interstitial  nephritis  develops  and  the  urine 
becomes  pale,  copious,  of  a  low  specific  gravity,  and  contains 
albumin  and  hyaline  casts.  Glycosuria  is  also  frequently  ob- 
served. 

Oircidatory  Phenomena. — High  arterial  tension,  accentua- 
tion of  the  aortic  second  sound,  and  later,  arterio-sclerosis  and 
hypertrophy  of  the  left  ventricle. 


GOUT.  299 

Complications  and  Sequels. — Interstitial  nephritis, 
arterio-sclerosis,  hypertrophy  of  the  heart,  apoplexy,  chronic 
bronchitis,  and  cutaneous  eruptions,  especially  eczema. 

Diagnosis. — The  symptoms  of  acute  gout  are  so  charac- 
teristic that  an  error  in  diagnosis  is  scarcely  possible. 

Chronic  gout  may  be  mistaken  for  chronie  rheumatism; 
but  the  former  attacks  especially  the  small  joints ;  it  begins 
in  the  great  toe ;  the  blood  contains  an  excess  of  uric  acid  ; 
and  the  symptoms  are  not  so  much  influenced  by  atmospheric 
changes  as  by  diet. 

Prognosis.- — ^As  regards  the  acute  form,  the  prognosis  is 
good.  The  liability  to  arterial  degeneration  and  to  nephritis, 
and  the  difficulty  in  securing  cooperation  in  carrying  out  the 
treatment  render  the  prognosis  of  chronic  gout  rather  unfavor- 
able. 

Treatment.  The  Acute  Attach. — The  best  remedy  is  col- 
chicum  ;  ten  to  twenty  drops  of  the  wine  well  diluted  should 
be  given  every  two  hours,  and  stopped  as  soon  as  the  symptoms 
subside.  Alkalies  are  valuable  adjuncts,  and  the  salts  of  potas- 
sium or  of  lithium  may  be  given  with  the  colchicum.  Quinine 
is  also  useful ;  it  may  be  given  in  doses  of  five  grains  thrice 
daily.  The  free  use  of  water  should  be  encouraged,  and  a 
water  containing  lithium,  like  the  Buffalo  lithia  water,  may 
be  recommended.  Constipation  should  be  relieved  by  a  full 
dose  of  blue  mass  or  a  saline  draught.  Opium  may  be  required 
for  the  relief  of  the  pain.  The  aifected  part  should  be  elevated 
and  wrapped  in  cotton-wool,  or  covered  with  warm  fomenta- 
tions or  with  cloths  soaked  in  lead- water  and  laudanum.  The 
diet  should  be  light  and  non-stimulating. 

Chrome  Gout. — The  diet  must  be  restricted  and  carefully 
arranged  for  each  patient.  Light  meats,  fish,  eggs,  and  oysters 
may  be  used  in  moderation  ;  sweet  fruits  should  be  avoided  ; 
starches  and  sugars  must  be  limited ;  and  the  use  of  liquors 
interdicted.  The  condition  of  the  tongue,  stomach,  and  urine 
will  indicate  the  value  of  this  or  that  dietary.  Mineral  waters 
are  often  serviceable,  and  Carlsbad,  Vichy,  and  Buffalo  lithia 
are  among  the  best.  Their  utility  will  be  enhanced  by  the  addi- 
tion of  a  teaspoonful  of  some  effervescing  salt  of  lithium  to 
each  potation.     A  free  secretion  of  the  skin  should  be  encour- 


300  CONSTITUTIONAL   DISEASES. 

aged  by  frequent  bathing  followed  by  friction.  The  bowels 
should  be  kept  regular  by  salines  or  by  the  occasional  use  of 
a  mercurial  laxative.  Graduated  exercise  holds  a  prominent 
place  in  the  therapy  of  gout.  When  the  digestive  powers  are 
particularly  weak,  mineral  acids  with  stryclinine  will  prcn'e 
useful.  General  tonics  are  sometimes  indicated.  The  special 
remedies  are  colchicum,  lithium,  and  iodide  of  potassium. 

^  Vini  sem.  colchici,  f^ss  ; 
Potass,  ioclidi,  gij  ; 
Liq.  potass;,  f^iss ; 

Tr.  zingiberis,  f^ij.— M.     (KoDGSON.) 
Sig. — A  teaspoonful  twice  daily  in  warm  water. 

Or  small  doses  of  colchicum  may  be  given  with — 

^  Litliii  benzoat.,  ^ij  ; 

Aq.  cinnamom.,  fsijss. — M.     (JACCOIJD.) 
Sig. — A  teaspoonful  in  a  wineglass  of  water  every  four  hours. 

The  arthritic  condition  is  best   treated  by  careful  massage 
and  warm  sulphur  baths. 


RHEUMATOID  ARTHRITIS. 

(Arthritis  Deformans,  Rheumatic  Gout.) 

f  Definition. — A  chronic  affection  of  the  joints  characterized 
by  destruction  of  the  cartilages,  new  osseous  formations,  im- 
mobility, and  deformity. 

Etiology. — Heredity  ;  early  adult  life ;  female  sex ;  con- 
tinued emotional  disturbances,  as  anxiety  and  grief;  enfeeble- 
ment  of  health  from  bad  hygienic  environment,  prolonged 
lactation,  and  from  frequent  pregnancies,  are  the  predisposing 
causes. 

Pathology. — Many  look  upon  rheumatoid  arthritis  as  a 
disease  which  is  related  both  to  gout  and  rheumatism.  Others 
regard  it  as  a  neurosis  and  allied  to  the  arthropathies  which 
are  met  with  in  chronic  affections  of  the  spinal  cord. 

The  cells  of  the  cartilages  and  of  the  synovial  membrane 
proliferate  and  lead  to  villous  or  nodular  outgrowths.  Tlie 
central  portions  of  the  cartilages  ultimately  wear  away  and 
leave  the  bones  exposed.      The   heads   of  the  bones  become 


RHEUMATOID  ARTHRITIS.  301 

smooth  and  hard  like  ivory,  and  thickened  from  exostoses. 
The  synovial  membrane  and  periarticular  tissues  are  likewise 
thickened  and  sometimes  infiltrated  with  bony  products.  The 
surrounding  muscles  are  generally  atrophied.  All  joints  are 
liable  to  be  affected. 

Symptoms. — It  may  be  either  acute  or  chronic/  the  latter  n 
being  the  more  common  form.  In  the  acute  foi'm  several 
joints  are  simultaneously  involved ;  they  become  swollen,  pain- 
ful, and  slightly  reddened.  There  is  moderate  fever.  The 
symptoms  soon  subside,  to  reappear,  however,  at  frequent 
intervals. 

In  the  chronio  form,  the  hands,  particularly  the  metacarpo- 
phalangeal joints,  are  usually  first  affected ;  then  the  wrists, 
knees,  toes,  jaws,  and  spine.  Symmetrical  joints  are  usually 
attacked.  The  symptoms  are  :  Swelling,  pain,  immobility,  and 
deformity ;  the  joints  are  stiff  and  creak  when  moved ;  later 
complete  anchylosis  develops ;  the  muscles  waste  and  con- 
tractures increase  the  deformity.  In  advanced  cases  the  fingers 
are  bent  backward,  often  locked,  and  turned  toward  the  ulnar 
side ;  the  thighs  are  drawn  up ;  the  legs  are  adducted  and 
flexed.     The  patient  may  be  a  helpless  invalid  for  many  years. 

Diagnosis.  Gout. — The  circumstances  under  which  gout 
develops ;  the  history  of  an  acute  attack  in  the  great  toe ;  the 
presence  of  uric  acid  in  the  blood ;  the  presence  of  urate  of 
soda  in  the  joints  and  in  the  cartilages  of  the  ear  will  serve  to 
distinguish  the  two  diseases. 

ChroniG  Rheumatism. — Unlike  chronic  rheumatism,  rheu- 
matoid arthritis  begins  in  the  small  joints,  passes  from  joint 
to  joint,  and  leaves  permanent  deformity. 

Prognosis. — Unfavorable.  Sometimes  the  disease  is  local 
and  remains  in  one  joint  (niono-articular  form).  Generally 
several  joints  are  affected,  and  while  judicious  and  persistent 
treatment  may  retard  the  progress  of  the  disease,  a  cure  is 
rarely  attainable. 

Treatment. — Good  hygiene.  Tonics  like  iron,  arsenic, 
phosphorus,  and  cod-liver  oil  are  useful.  The  most  gOod  is 
to  be  expected  from  local  treatment,  which  consists  of  massage, 
electricity,  steam  baths,  and  inunctions  of  preparations  con- 
taining iodine  or  mercuiy. 


302  CONSTITUTIONAL  DISEASES. 

KICKETS. 

(Rachitis.) 

Definition, — ^A  constitutional  disease  of  early  childhood, 
characterized  chiefly  by  defective  nutrition  of  the  osseous 
structures. 

Etiology, — Rickets  is  rarely  congenital ;  it  usually  de- 
velops between  the  first  and  second  years.  Poverty,  artificial 
feeding,  and  bad  hygienic  conditions  are  the  predisposing 
causes. 

Pathology. — The  most  marked  changes  are  observed  in 
the  long  bones  and  ribs.  The  cartilaginous  lamina  between 
the  epiphysis  and  the  shaft  are  considerably  thickened,  and 
are  spongy  and  irregular  in  outline ;  microscopic  examination 
reveals  an  excessive  proliferation  of  the  cartilage-cells  with 
scanty  calcification.  The  periosteum  is  thickened  and  highly 
vascular,  and  when  stripped  off  soft  porous  bone  is  exposed. 
The  bones  are  soft,  being  extremely  deficient  in  lime-salts ; 
when  ossification  finally  results  the  bones  become  heavy,  large, 
and  irregular  in  outline ;  these  changes  correspond  to  the  clinical 
phenomena — bow-legs,  knock-knees,  spinal  curvature,  pigeon- 
breast,  and  square  cranium. 

The  liver  and  spleen  are  often  considerably  enlarged. 

Symptoms. — The  early  symptoms  are :  Restlessness  and 
slight  fever  at  night ;  free  perspiration  about  the  head ;  dif- 
fuse soreness  and  tenderness  of  the  body ;  pallor ;  slight  diar- 
rhoea ;  enlargement  of  the  liver  and  spleen  ;  delayed  dentition 
and  the  eruption  of  badly-formed  teeth. 

Skeletal  Phenomena. — The  head  is  large  and  more  or  less 
square  in  outline ;  careful  palpation  may  detect  soft  areas. 
The  sides  of  the  thorax  are  flattened ;  the  sternum  is  promi- 
nent ;  nodules  can  be  felt  at  the  sternal  ends  of  the  ribs — 
"  rachitic  rosary"  ;  there  may  be  a  distinct  transverse  groove  at 
the  level  of  the  ensiform  cartilage;  the  spinal  column  is  fre- 
quently curved  antero-posteriorly  or  laterally  ;  the  long  bones 
are  curved  and  prominent  at  their  extremities. 

Complications. — Green-stick  fractures,  convulsions,  laryn- 
gismus stridulus,  paresis  of  the  extremities,  and  acute  pulmo- 


LITH^MIA.  303 

nary  diseases.     In  women  the  rachitic  pelvis  may  seriously 
complicate  labor. 

Prognosis. — Rachitis  does  not  kill  directly,  but  death  is  not 
uncommon  from  intercurrent  disease.  Under  good  hygienic 
conditions  recovery,  with  more  or  less  deformity,  generally 
follows. 

Treatment, — The  general  nutrition  must  be  improved  by 
placing  the  child  under  the  best  hygienic  conditions.  Eggs, 
pure  milk,  prepared  food,  and  broths  should  be  recommended. 
Cod-liver  oil  is  a  valuable  nutrient  tonic.  Iron  is  indicated 
for  the  ansemia.  The  lack  of  calcareous  material  in  the  bones  , 
should  be  supplied  by  the  administration  of  phosphorus  and  / 
lime- salts. 

"^  Syr,  ferri  iodid. ,  f^iss  ; 
Mist,  ol,  morrhuiB  et 

Lactophos,  calcis,  q.  s.  ad  f^iij, — M,    (Starr.) 
Sig. — From  one-half  to  a  teaspoonful  three  times  a  day. 

LITH^MIA. 

(Lithic-acid  Diathesis,  Uric-acid  Diathesis,  Latent  Gout.) 

Definition. — A  constitutional  disease  dependent  upon  mal- 
assimilation  of  nitrogenous  products  and  the  formation  of  uric 
acid  aud  allied  substances  instead  of  urea,  and  characterized 
by  an  excess  of  uric  acid  in  the  urine,  and  varied  digestive, 
circulatory,  and  nervous  phenomena. 

Etiology. — Gout  with  an  acute  arthritic  expression  is  un- 
common in  America,  but  latent  gout,  or  litheemia,  is  extremely 
common.  Impaired  digestion,  insufficient  exercise,  mental 
strain,  and  over-eating  are  the  usual  causes. 

Symptoms.  Gastro-intestinal  Phenomena. — The  tongue  is 
generally  coated  and  the  breath  heavy  ;  the  appetite  is  variable, 
sometimes  it  is  lost,  at  others  it  is  inordinate  ;  acid  eructations, 
"  heartburn,"  and  flatulence  are  frequent  gastric  symptoms ; 
the  bowels  are  usually  constipated. 

Urinary  Phenomena. — The  urine  is  scanty,  high-colored,  of 
high  specific  gravity  (1025  - 1035),  and  on  standing  throws 
down  an  abundant  brick-dust  sediment.  The  solids  render 
the  urine  irritating,  so  that  dull  aching  in  the  loins  and  burn- 


304  CONSTITUTIONAL,  DISEASES. 

ing  in  the  penis  after  micturition  are  common  symptoms.  A 
trace  of  sugar  is  sometimes  detected  on  chemical  examination.' 
The  urine  often  stains  the  clothes  red. 

Circulatory  Phenomena. — High  arterial  tension,  accentua' 
tion  of  the  aortic  second  sound,  and  a  tendency  to  atheroma. 

Nervous  Phenomena. — Headache,  vertigo,  disturbed  sleep, 
tinnitus  aurium,  depression  of  spirits,  failure  of  memory,  loss 
of  energy,  irritability,  and  neuralgic  pain  in  various  parts  of 
the  body. 

Sequels.  —  Arterial  degeneration,  interstitial  nephritis, 
hepatic  cirrhosis,  gastritis,  renal  or  vesical  calculi. 

Diagnosis. — This  rests  on  the  general  symptoms  and  the 
analysis  of  the  urine. 

Pkognosis.  —  Favorable  under  prolonged  and  judicious 
treatment. 

Treatment. — Special  attention  must  be  given  to  the  diet. 
It  is  a  mistake  to  cut  off  alf  nitrogenous  foods,  for  often  the  chief 
difficulty  is  in  digesting  the  starches  and  sugars.  Light  meats, 
green  vegetables,  eggs,  and  oysters  are  admissible.  The  use 
of  fats,  heavy  meats,  sweets,  starches,  and  alcoholic  beverages 
must  be  restricted.  Next  to  diet,  regular  exercise  is  the  most 
important  therapeutic  measure ;  the  patient  must  eat  less  or 
burn  up  more  material,  and  the  chief  stimulant  of  tissue-metab- 
olism is  exercise.  A  change  of  scene  may  effect  brilliant  results. 
Frequent  bathing  with  salt  water  followed  by  friction  is  a 
valuable  adjunct.  When  the  gastric  digestion  is  weak,  mineral 
acids,  strychnine,  and  pepsin  are  useful  remedies.  The  salts  of 
potassium  and  lithium  are  solvents  of  uric  acid  ;  citrate  of 
lithium  (gr.  xx),  benzoate  of  lithium  (gr.  v),  or  citrate  of  potas- 
sium (gr.  xx),  may  be  given,  well  diluted,  two  hours  after 
meals.  Mineral-waters  containing  these  salts  may  be  recom- 
mended. The  bowels  should  be  kept  regular  by  some  simple 
laxative. 

DIABETES. 

(Diabetes  Mellitus.) 

Definition. — A  nutritional  disease,  characterized  by  the 
persistent  presence  of  sugar  in  the  urine,  polyuria,  and  loss  of 
flesh  and  strength. 


DIABETES.  305 

Etiology. — Heredity,  adult  life,  male  sex,  the  Hebrew  \ 
race,  prolonged  meutal  anxiety,  and  dietetic  errors  are  pre- 
disposing causes.    It  rarely  follows  injury  of  the  brain  or  cord. 

Pathology. — The  lesions  found  after  death  have  been  so 
varied  that  the  condition  which  is  really  responsible  for  diabetes 
is  still  undetermined.  Puncture  of  the  floor  of  the  fourth 
ventricle  will  produce  glycosuria,  but  the  cases  are  rare  in 
which  lesions  of  this  region  have  been  found  after  death.  In 
a  notable  number  of  cases  the  pancreas  is  the  seat  of  cirrhosis 
and  of  fatty  degeneration,  but  the  relation  of  this  condition  to 
diabetes  is  still  unknown.  The  liver  is  frequently  enlarged  and 
the  seat  of  degeneration  changes.  The  kidneys  are  enlarged 
and  often  reveal  evidences  of  parenchymatous  inflammation. 

According  to  one  view,  diabetes  has  its  origin  in  the  sympa- 
thetic nervous  system,  and  results  from  a  vaso-motor  dilatation 
of  the  hepatic  vessels  causing  a  disturbance  of  the  glycogenic 
function  of  the  liver  and  the  discharge  of  glucose  in  the  urine. 

According  to  another  theory,  diabetes  results  from  a  func- 
tional or  organic  disease  of  those  organs,  particularly  the  pan- 
creas and  liver,  which  are  engaged  in  the  assimilation  of 
starches  and  sugars. 

Symptoms.  Urinary  Phenomena. — The  urine  is  increased 
in  quantity,  the  amount  varying  frofn  three  or  four  pints  to  as 
many  gallons ;  its  color  is  pale ;  its  specific  gravity  ranges 
from  1015  to  1050 ;  it  has  a  sweetish  taste  and  an  aromatic 
odor.  In  summer  it  attracts  flies  and  rapidly  ferments.  It 
may  leave  a  whitish  residue  on  the  clothes.  The  percentage  of 
glucose  varies  from  a  half  per  cent,  to  ten  per  cent. ;  the  total  \ 
amount  excreted  in  twenty-four  hours  varies  from  a  few  ounces  ■ 
to  a  pound  or  more.    , 

General  Phenomena. — There  is  loss  of  flesh  and  strength  ;     , 
the  temperature  is  normal  or  subnormal ;  the  appetite  is  often   \j 
inordinate,    and    the    thirst    unquenchable;    the    tongue    is    / 
generally  fissured  and  beefy-red  ;  the  bowels  are  usually  con- 
stipated. 

Cutaneous  Phenomena. — The  skin  is  harsh  and  dry,  and  fre- 
quently the  seat  of  intense  itching.     Pruritus  is  especially  ob- 
served at  the  genitalia,  and  this  may  be  the  first  subjective 
symptom. 
20 


306  CONSTITUTIONAL  DISEASES. 

Nervous  Phenomena. —  Headache,  depression  of  spirits, 
diminished  or  lost  patellar  reflexes,  impaired  sexual  power, 
dimness  of  vision,  and  neuralgia. 

The  duration  varies  from  a  few  weeks  in  the  acute  form  to 
many  years  in  the  chronic  form. 

Complications.  —  Pulmonary  tuberculosis,  pneumonia, 
gangrene  of  the  lung ;  defective  vision  from  soft  cataract, 
retinitis  or  atrophy  of  the  optic  nerve ;  cutaneous  lesions,  as 
boils,  eczema,  carbuncles,  and  gangrene;  nephritis;  neuritis 
and  diabetic  coma,  or  acetoncemia. 

This  last  condition  is  characterized  by  epigastric  pain,  dys- 
pnoea, a  sweetish  odor  of  the  breath,  headache,  delirium,  stupor, 
and  coma ;  it  probably  results  from  the  presence  of  diacetic  and 
oxybutyric  acids  in  the  blood. 

Diagnosis. — Care  must  be  taken  to  distinguish  simple  gly- 
cosuria from  diabetes.  The  former  is  recognized  by  being 
transient,  and  unassociated  with  the  constitutional  symptoms  of 
diabetes. 

Pruritus  and  apparently  causeless  loss  of  flesh  and  strength 
should  lead  to  a  suspicion  of  diabetes. 

Prognosis. — The  younger  the  patient,  the  stronger  the 
hereditary  tendency,  the  larger  the  amount  of  sugar  excreted, 
the  less  the  glycosuria  can  be  controlled  by  diet  alone,  the 
graver  the  prognosis.  On  the  other  hand,  when  it  occurs  after 
middle  life  in  association  with  a  gouty  diathesis,  and  the  gly- 
cosuria is  not  pronounced,  the  prognosis  for  a  long  duration  is 
comparatively  favorable.     Absolute  cure  is  rarely  attainable. 

Treatment.  Dietetic  Treatment. — Sugars  and  starches 
must  be  restricted.  Since  the  patient's  appetite  is  often  inordi- 
nate, it  is  necessary  to  regulate  the  quantity  and  character  of 
those  foods  which  are  recognized  as  admissible.  The  following 
foods  may  be  included  in  the  dietary  : — 

Animal  Foods. — Meats  of  various  kinds  (except  liver), 
game,  light  broths  and  soups,  fish,  and  eggs. 

Vegetables. — Celery,  lettuce,  cauliflower,  tomatoes,  mush- 
rooms, string-beans,  young  onions,  olives,  water-cress,  and 
spinach. 

Beverages. — Buttermilk,  skim  milk,  sour  wines  (Rhine 
wines),  carbonated  waters,  and  cofiee  and  tea  without  sugar. 


DIABETES.  307 

Relishes. — Nuts  of  all  kinds  (except  chestnuts),  cream  chfeese, 
and  pickles. 

Bread. — Bread  made  of  gluten,  bran  flour,  or  almond  flour. 
It  should  be  borne  in  mind  that  all  the  gluten  flours  are  rich 
in  starch. 

Fruits. — Cranberries,  sour  cherries,  limes,  lemons,  and  red 
currants. 

Substitutes  for  Sugar. — Saccharin  and  glycerin. 

The  following  foods  should  be  avoided :  Liver,  oysters, 
wheat  bread,  biscuits,  pastry,  potatoes,  beets,  carrots,  peas, 
turnips,  parsnips,  sweet  fruits,  rice,  barley,  tapioca,  corn-starch, 
corn-meal,  chocolate,  cocoa,  syrups,  preserves,  and  most  liquors. 

Hygienic  Treatment. — Graduated  exercise  ;  frequent  bathing 
with  salt  water  followed  by  friction ;  the  use  of  flannel 
underclothing ;  plenty  of  rest  and  sleep ;  and,  if  possible,  a 
change  of  scene. 

Medicinal  Treatment. — Tonics  like  iron,  arsenic,  strychnine, 
alcohol,  and  cod-liver  oil  are  often  indicated.  The  special  reme- 
dies are  opium'and  its  alkaloids — morphine  and  codeine — bro- 
mide of  arsenic,  ergot,  antipyrin,  salicylate  of  sodium,  and  alka- 
lies. Opium  is  generally  the  most  useful  drug;  it  should  be 
given  in  small  doses  gradually  increased  until  the  patient  takes 
five  or  six  grains  daily.  Codeine  (gr.  ^  increased  to  gr.  vj  a 
day)  has  been  thought  preferable  to  either  opium  or  morphine, 
but  according  to  the  clinical  experiments  of  Bruce  and  Osier, 
morphine  is  much  more  reliable.  The  latter  may  be  employed 
in  doses  of  one-fourth  of  a  grain  three  or  four  times  daily. 
The  bromide  of  arsenic  is  sometimes  of  decided  value;  it  may 
be  given  in  the  following  solution  : — 

^j^:.   Liq.  arsenici  brom.  (Clemens),  f§j. 
Sig. — Two  to  five  drops  well  diluted  after  meals. 

In  gouty  patients  a  course  of  Carlsbad  water  with  salicylate 
of  sodium  (gr.  iij-v  thrice  daily)  and  antipyrin  (gr.  v-x  thrice 
daily)  may  be  recommended,  or : — 

^  Sodii  salicylat.,  ^iij  ; 

Liq.  potass,  arseuitis,  f^j  ; 
Glycerini,  f^j ; 

Aq.  cinnamorai,  ad  ^iij. — M.     (J.  C.  Wilsok.) 
Sig. — A  teaspoonful  to  a  dessertspoonful  thrice  daily 


308  CONSTITUTIONAL   DISEASES. 

I^iabetic  coma  is  always  fatal,  but  the  iutravenous  injection 
of  a  copious  solution  (3  per  cent.)  of  bicarbonate  of  sodium 
may  give  a  few  hours'  respite,  in  which  consciousness  returns. 

DIABETES  INSIPIDUS. 

Definition. — A  chronic  condition  characterized  by  the 
excretion  of  large  quantities  of  pale,  limpid  urine  of  low  specific 
gravity  and  free  from  albumin  and  sugar. 

Etiology. — Diabetes  insipidus  must  be  distinguished  from 
the  simple  polyuria  observed  in  chronic  renal  disease,  in  cer- 
tain diseases  of  the  brain,  and  ii\  some  cases  of  hysteria. 

Diabetes  insipidus  sometimes  develops  without  obvious 
cause.  It  is  more  common  in  the  young,  and  more  males  are 
attacked  than  females.  It  is  occasionally  hereditary.  It  has 
been  induced  by  injury  and  by  certain  diseases  of  the  brain. 
Profound  emotional  disturbance  has  excited  it.  Syphilis, 
overwork,  and  the  free  use  of  cold  water  when  the  body  has 
been  overheated,  are  reputed  causes. 

Pathology. — Little  is  known  of  the  pathology.  The 
kidneys  are  frequently  enlarged  and  congested,  and  the  ureters 
dilated. 

The  theory  which  is  generally  accepted  as  accounting  for 
the  polyuria,  is  that  it  is  due  to  a  vaso-motor  paresis  of  the 
renal  vessels,  which  permits  a  free  transudation  of  liquid. 

Symptoms. — The  disease  may  begin  insidiously  or  abruptly; 
the  latter  is  the  rule.  The  urine:  The  quantity  is  increased, 
often  as  much  as  eight  or  ten  quarts  being  excreted  in  the 
twenty-four  hours  ;  it  is  pale,  and  resembles  water ;  it  has  a 
specific  gravity  of  1002-1005.  The  total  amount  of  solids  is 
not  diminished.  Albumin  and  sugar  are  generally  absent, 
though  there  may  be  a  trace  of  the  latter. 

General  Symptoms. — Insatiable  thirst;  good  appetite;  a 
harsh,  dry  skin  ;  a  dry  tongue ;  constipation  ;  mental  apathy  ; 
and  emaciation. 

Duration. — When  unassociated  with  organic  disease  the 
duration  may  be  indefinite. 

Complications. — These  are  much  less  common  than  in 
diabetes  mellitus.  Cataract,  pruritus,  boils,  and  tuberculosis 
have  been  observed. 


DIABETES   INSIPIDUS.  309 

Diagnosis.  Diabetes  MelUtus. — The  low  si^ecific  gravity 
of  the  urine  and  the  absence  of  sugar  will  serve  to  distinguish 
diabetes  insipidus  from  diabetes  mellitus. 

Interstitial  Nephritis. — The  presence  of  albumin,  hyaline 
casts,  high  arterial  tension,  accentuation  of  the  aortic  second 
sound,  and  the  cardiac  hypertrophy  will  indicate  nephritis. 

Symptomatic  Polyuria. — -The  history  and  a  careful  physical 
examination  will  usually  prevent  an  error  in  diagnosis. 

Peognosis. — Usually  unfavorable.  A  permanent  cure  is 
sometimes  effected.  Death  results  from  exhaustion,  or  more 
frequently,  from  some  intercurrent  disease. 

Treatment. — The  hygienic  treatment  suggested  for  diabetes 
mellitus  is  applicable  in  this  disease.  No  benefit  is  derived 
from  cutting  oif  the  amount  of  water  drunk.  Lemonade  and 
other  acid  drinks  may  serve  to  lessen  the  amount  of  liquid 
consumed. 

The  remedies  recommended  are  ergot,  strychnine,  opium, 
valerian,  and  nitric  acid.  Galvanism — one  pole  applied  to 
the  neck- and  the  other  to  the  loins — has  given  good  results. 
When  syphilis  is  suspected,  the  mercurials  and  iodides  maybe 
administered  freely  with  good  hopes  of  a  successful  issue. 

^L  Pulv.  opii,  gr.  iv  ; 

Acid,  gallici,  ^ij.— M.     (H.  C.  Wood.) 
Ft.  in  chart.  ISTo.  xii. 
Sig. — One,  three  or  four  times  daily. 


DISEASES 


NERVOUS  SYSTEM, 


DISTTJRBAIVCES  OF  MOTION. 

These  coDsist,  for  the  most  part,  of  loss  of  power,  or  para- 
lysis, and  manifestation  of  motor  excitation,  such  as  convul- 
sions, choreiform  movements,  and  tremors. 

Paralysis. 

The  paralysis  may  be  irregularly  distributed,  or  it  may  in- 
volve a  single  member,  when  it  is  termed  monoplegia  ;  a  lateral 
half  of  the  body,  when  it  is  termed  hemiplegia  ;  or  the  body 
from  the  waist  down,  when  it  is  termed  paraplegia. 

Irregular  paralysis  may  result  from  : — 

1.  Disseminated  lesions  in  the  motor  areas  of  the  brain, 
which  are  commonly  syphilitic. 

2.  Lesions  in  the  basal  ganglia — pons,  crura  cerebri,  medulla, 
when  it  is  often  associated  with  headache,  vomiting,  vertigo, 
and  optic  neuritis. 

3.  Acute  poliomyelitis.  This  develops  abruptly  ;  it  occurs 
in  young  children  ;  and  it  is  followed  by  rapid  improvement  in 
some  muscles  and  permanent  atrophy  and  paralysis  in  others. 

4.  Chronic  poliomyelitis.  This  develops  in  middle  life; 
begins  in  the  small  muscles  of  the  hand ;  is  associated  with 
atrophy ;   and  progresses  very  slowly. 

5.  Idiopathic  muscular  atrophy.  This  commonly  develops 
during  adolescence ;  involves  the  muscles  of  the  arm,  shoulder, 

(310) 


DISTURBANCES  OF  MOTION.  311 

buttocks,  and  thigh ;  is  associated  with  atrophy ;  and  can  be 
frequently  traced  to  heredity, 

6.  Pseudo-muscular  hypertrophy.  This  develops  in  child- 
ren ;  is  associated  with  enlargement  of  the  affected  muscles ; 
and  can  be  frequently  traced  to  heredity. 

7.  Multiple  neuritis.  This  is  recognized  by  the  history, 
pain,  disturbances  of  sensation,  and  tenderness  over  the  nerve- 
trunks. 

8.  Syringo-myelia.  This  is  rare ;  develops  during  ado- 
lescence ;  and  is  recognized  by  pains,  atrophy  of  the  affected 
muscles,  a  spastic  condition  of  the  paralyzed  members,  and  a 
loss  of  thermic  and  painful  sensations,  while  tactile  sensation 
is  retained. 

Monoplegia  may  result  from  : — 

1.  A  focal  lesion  in  the  cortical  area  of  the  brain.  This 
may  be  recognized  by  the  history,  the  absence  of  wasting,  of 
sensory  disturbances,  and  of  the  reactions  of  degeneration. 

2.  A  lesion  of  the  peripheral  nerve,  from  traumatism,  neu- 
ritis, or  the  pressure  of  a  tumor;  Brachial  monoplegia  fre- 
quently results  from  the  pressure  of  the  head  on  the  arm 
during  sleep.  Monoplegia  of  peripheral  origin  is  recognized 
by  the  history,  the  wasting,  the  sensory  disturbances,  and  the 
presence  of  reactions  of  degeneration. 

3.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament ;  the  paroxysmal  character  of  the  paralysis ; 
the  disturbances  of  sensation ;  and  contractures  without  atrophy 
or  electrical  disturbances. 

Facial  monoplegia  may  result  from  a  small  lesion  in  the 
facial  centre  of  the  cortex  or  in  the  medulla ;  or  from  involve- 
ment of  the  nerve  in  the  canal  of  the  temporal  bone ;  or  after 
its  exit  from  the  stylo-mastoid  foramen. 

Facial  dijilegia  (double  facial  paralysis)  generally  results 
from  a  lesion  at  the  base  of  the  brain. 

Hemiplegia  may  result  from  : — 

1 .  A  diffuse  lesion  of  the  motor  cortex.  The  paralysis  is 
on  the  opposite  side  of  the  body  and  is  unassociated  with 
anaesthesia. 

2.  A  lesion  of  the  internal  capsule  or  the  adjacent  ganglia 
(corpus   striatum   and   optic   thalamus).      This  is   the  most 


312  t)ISEASES   OF   THE   iSTERVOUS   SYSTEM. 

common  seat  of  hemorrhage ;  the  paralysis  is  on  the  opposite 
side  of  the  body  and  is  unassociated  with  anaesthesia. 

3.  A  lesion  of  the  cms  cerebri.  This  frequently  produces 
hemiplegia  and  hemiansesthesia  on  the  opposite  side,  and  par- 
alysis of  the  oculo-motor  nerve  on  the  side  of  the  lesion,  indi- 
cated by  dilated  pupil,  strabismus,  and  ptosis. 

4.  A  lesion  of  the  pons.  This  frequently  produces  hemi- 
plegia and  hemianaesthesia  on  the  opposite  side,  and  facial 
paralysis  on  the  side  of  the  lesion. 

5.  A  lesion  in  the  medulla.  This  is  rare,  and  is  associated 
with  paralysis  of  the  cranial  nerves,  difficult  articulation,  car- 
diac and  respiratory  disturbances,  and  vomiting. 

6.  A  unilateral  lesion  high  in  the  cord  (very  rare).  This 
produces  a  spastic  paralysis  on  the  side  aifected,  and  hemianses- 
thesia  on  the  opposite  side  {"  Brown-Sequard's  paralysis"). 

7.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament;  by  being  frequently  paroxysmal;  by  its 
association  with  sensory  disturbances ;  by  the  absence  of  wast- 
ing and  of  abnormal  electrical  reactions ;  and  by  the  escape  of 
the  facial  muscles. 

Paraplegia  may  result  from  : — 

1.  Hemorrhage  into  the  cord  at  the  dorsal  region.  The 
paralysis  develops  abruptly,  and  is  associated  with  complete 
anaesthesia  and  involvement  of  the  bladder  and  rectum. 

2.  Hemorrhage  into  the  membranes  of  the  cord.  The  par- 
alysis develops  rapidly,  but  more  slowly  than  the  preceding ; 
is  associated  with  intense  tearing  pains  and  incomplete  anaes- 
thesia. 

3.  Some  forms  of  multiple  neuritis.  This  is  recognized  by 
the  pains,  the  disturbances  of  sensation,  the  tenderness  over  the 
nerve-trunks,  and  the  absence  of  "  girdle  pain"  and  sphincter 
involvement. 

4.  Fracture  of  the  vertebrae. 

5.  Acute  myelitis.  The  paralysis  develops  in  the  course  of 
a  few  days,  and  is  associated  with  anaesthesia,  bedsores,  involve- 
ment of  the  bladder  and  rectum,  loss  of  reflexes,  and  wasting 
of  the  muscles. 

6.  Landry's  disease  (acute  ascending  paralysis).  This  de- 
velops in  the  course  of  a  few  days,  and  is  unassociated  with 


DISTUKBANCES  OF   MOTION.  313 

anaesthesia,  wasting  of  the  muscles,  bedsores,  or  sphincter  in- 
volvenjeut. 

7.  Chronic  myelitis.  This  develops  over  several  years,  and 
is  associated  with  nnmbness  and  tingling,  increased  reflexes, 
involvement  of  the  bladder  and  rectum,  and  anaesthesia. 

8.  Compression  of  the  cord  from  morbid  growths,  aneurism, 
or  spinal  caries.  This  may  be  recognized  by  the  history,  the 
symptoms  of  the  primary  disease,  the  anaesthesia  or  hyper- 
aesthesia,  and  the  intense  pains  radiating  along  the  line  of  the 
spinal  nerves. 

9.  Lateral  sclerosis.  This  develops  slowly  and  is  associated 
with  a  spastic  condition  of  the  muscles  and  with  increased 
reflexes,  and  lacks  sensory  disturbances. 

10.  Injury  of  the  brain  in  delivery  (spastic  paraplegia  of 
infants).  The  symptoms  resemble  lateral  sclerosis,  and  are 
often  associated  with  imbecility  or  idiocy. 

11.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament ;  by  being  frequently  paroxysmal ;  and  by 
the  absence  of  wasting  and  of  abnormal  electrical  reactions. 

12.  Caisson  disease  (divers'  paralysis).  The  history  will 
establish  the  diagnosis. 

Convulsions. 

A  convulsion  is  a  condition  in  which  there  are  excessive 
muscular  contractions,  continued  or  intermittent,  dependent 
upon  an  involuntary  discharge  of  motor  impulses  from  the 
nerve-centres. 

Intermittent  contractions  are  termed  clonic  ;  continued  con- 
tractions, tonic. 

Convulsions  may  be  general  or  local.  The  term  spasm  is 
sometimes  applied  to  the  latter. 

There  is  no  real  line  of  distinction  between  convulsions, 
choreiform  movements,  and  tremors. 

Varieties  of  Convulsions. — Three  varieties  are  frequently 
made:  (1)  Epileptiform  ;  (2)  tetanic;  (3)  hy steroidal. 

Epileptiform  Convulsions. — In  this  form  there  is  uncon- 
sciousness, and  the  movements  are  for  the  most  part  clonic. 
Epileptiform  convulsions  may  result  from  : — 


314  DISEASES  OF  THE   NERVOUS  SYSTEM. 

1.  Idiopathic  epilepsy.  This  condition  usually  develops 
before  puberty,  and  the  convulsions  are  general  and  are 
unassociated  with  any  definite  cause. 

2.  Organic  brain  disease.  In  this  condition  there  may  be 
a  history  of  syphilis  or  of  injury;  the  convulsions  maybe 
local,  or  begin  as  such  and  become  general ;  and  there  may  be 
concomitant  symptoms  of  cerebral  disease. 

3.  Toxic  agents  in  the  blood.  Alcoholism,  the  infectious 
fevers,  and  uraemia  are  frequently  associated  with  convulsions. 

4.  Reflex  irritation.  Such  convulsions  are  usually  observed 
in  young  children,  and  result  from  gastric  irritation,  an  ad- 
herent prepuce,  intestinal  parasites,  or  teething.  Convulsive 
seizures  sometimes  result  from  the  injection  of  substances  into 
the  pleural  sac  for  the  cure  of  hydrothorax. 

5.  Cerebral  anaemia.  Such  convulsions  are  seen  after  pro- 
fuse hemorrliage,  in  fatty  heart,  and  in  poisoning  from  cardiac 
paralyzants  like  aconite  and  veratrum  viride. 

Edam'psia.  This  term  is  applied  to  designate  accidental 
convulsions,  such  as  the  convulsions  of  childhood  resulting 
from  reflex  irritation,  and  the  convulsions  of  pregnancy  or 
the  puerperium,  resulting  from  toxic  materials  retained  in  the 
blood. 

Tetanic  Convulsions. — In  this  form  the  discharges  emanate 
from  the  spinal  cord,  and  are  not  associated  with  a  loss  of  con- 
sciousness.    Tetanic  convulsions  may  result  from  : — 

1.  Tetanus.  This  is  recognized  by  the  history  of  a  wound, 
the  tonic  character  of  the  convulsions,  the  early  involvement 
of  the  jaw,  and  the  absence  of  fever. 

2.  Spinal  meningitis.  This  is  recognized  by  exquisite  pain 
in  the  back,  fever,  and  late  involvement  of  the  jaw. 

3.  Strychnia-poisoning.  This  is  recognized  by  the  history, 
the  intermittent  character  of  the  convulsions,  the  absence  of 
fever,  and  the  escape  of  the  muscles  of  the  jaw  until  very  late. 

4.  Tetany.  In  this  condition  the  extremities  are  chiefly  in- 
volved; the  convulsions  are  intermittent,  and  can  be  produced 
by  pressure  on  the  nerves  and  arteries  of  the  affected  limbs. 

Hysteroidal  Convulsions. — These  are  manifestations  of  hys- 
teria, and  in  them  consciousness  is  only  partially  or  apparently 
lost.     They  are  not  preceded  by  an  aura,  but  sometimes  by  a 


DISTUEBANCES   OF   MOTION.  315 

sensation  of  a  ball  in  the  throat — the  "globus  hystericus  ;"  the 
eyes  are  partially  closed ;  the  face  expresses  some  emotion ; 
the  tongue  is  not  bitten  ;  the  movements  are  tonic,  or  if  clonic, 
appear  wilful ;  the  paroxysm  is  of  long  duration  ;  and  the 
patient  frequently  weeps  or  laughs. 

Local  Convulsions  or  Spasm. — Spasm  of  the  face  may  result 
from  a  (1)  cortical  lesion  in  the  inferior  portion  of  the  ascend- 
ing frontal  convolution  ;  (2)  from  tic  convulsif — a  condition 
occurring  in  young  children,  affecting  the  facial  and  neighbor- 
ing muscles,  and  associated  with  mimicry,  a  tendency  to  use 
profane  language,  and  various  mental  disturbances ;  (3)  from 
habit  (habit- chorea)  ;  and  sometimes  from  (4)  tic  douloureux — 
neuralgia  of  the  fifth  nerve. 

Temporary  spasms  of  one  arm  or  one  leg  are  usually  mani- 
festations of  Jacksonian  epilepsy  (focal  epilepsy),  but  they 
sometimes  result  from  hysteria. 

Spasm  of  the  hand  developing  ivhen  the  member  is  put  to  use 
may  result  from  writers'  cramp,  Thomsen's  disease,  or 
hysteria. 

Spasm  of  the  cervical  muscles  (wry-neck,  torticollis)  may 
result  from  congenital  shortening  of  the  sterno-mastoid,  myal- 
gia, hysteria,  caries  of  the  vertebrae,  or  the  irritation  of  en- 
larged cervical  glands. 

Spasms  of  the  larynx,  oesophagus,  and  diaphragm  (hiccough) 
have  already  been  discussed. 

Saltatory  Spasm. — This  term  is  employed  to  designate  a 
condition  allied  to  hysteria,  in  which  a  violent  spasm  seizes  the 
muscles  of  the  leg  as  soon  as  the  feet  touch  the  ground,  and 
as  a  result  the  patient  is  thrown  violently  into  the  air. 

Salaam  Convulsions. — These  consist  of  violent  paroxysmal 
bobbing  movements  of  the  head  or  trunk,  and  may  be  asso- 
ciated with  hysteria,  chorea,  or  rarely,  organic  brain  disease. 

Choreiform  Movements. 

These  are  coarse,  jerky,  irregular,  involuntary  movements 
which  more  or  less  simulate  purposive  movements.  They  may 
result  from  : — 

1.  Idiopathic  chorea  CSt.  Vitus's  dance).     This  disease  is 


316  DISEASES   OF  THE   NERVOUS  SYSTEM. 

seen  in  children  ;    is  usually  mild ;  runs  a  course  of  several 
weeks ;  and  is  prone  to  be  followed  by  endocarditis. 

2.  Chorea  insaniens.  A  grave  disease  occurring  in  adults, 
especially  pregnant  women,  and  characterized  by  violent  move- 
ments, delirium,  and  fever. 

3.  Huntingdon's  chorea  (chronic  chorea).  An  affection  oc- 
curring in  adult  life,  geuerally  hereditary,  and  characterized 
l)y  irregular  movements,  disturbance  of  speech,  and  increasing 
dementia. 

4.  Organic  brain  disease.  Choreiform  movements  are  fre- 
quently observed  in  cerebral  palsies  of  children ;  they  may 
also  develop  on  one  side  of  the  body  before  an  attack  of  apo- 
plexy fpre-hemiTjlegic  chorea),  or  in  the  paralyzed  members 
after  the  hemorrhage  (posMiejiiiplegic  chorea). 

5.  Peripheral  irritation.  Choreiform  movements  sometimes 
develop  in  pregnancy,  and  are  occasionally  noted  in  stumps 
after  amputation.  J)w»^'<*' 

6.  Habit.  Children  frequently  acquire,  through  constant 
repetition  or  mimicry,  choreiform  movements  which  may  last 
indefinitely. 

7.  Hysteria.  The  marked  rhythmical  character  of  the 
movements  and  the  history  will  aid  in  the  recognition  of 
hysterical  chorea. 

8.  Disseminated  cerebro-spinal  sclerosis.  This  disease  usu- 
ally induces  tremors,  but  not  uncommonly  the  movements  are 
choreiform.  The  increased  reflexes,  the  nystagmus,  the  loss 
of  power,  the  spastic  gait,  and  the  impairment  of  intellect 
will  aid  in  its  recognition. 

9.  Paramyoclonus  multiplex.  A  very  rare  disease,  of  un- 
known origin,  characterized  by  continued  or  paroxysmal 
choreiform  movements  which  develop  or  increase  under  ex- 
cilement  or  movement. 

Athetosis. 

This  term  was  employed  by  Hammond  to  designate  certain 
movements  occurring  chiefly  in  the  hands  and  feet,  and  charac- 
terized by  slow  twisting,  intertwining,  separation,  and  exten- 
sion of  the  fingers  and  toes.     Athetosis  is  frequently  observed 


DISTURBANCES  OP  MOTION.  317 

in  the  cerebral  pj^Jsies  of  children,  and  it  occasionally  occurs 
in  adults  as  a  result  of  lesions  in  the  basal  ganglia. 

Tremors. 

A  tremor  is  a  fine  vibratory  movement  due  to  the  alternate 
contraction  and  relaxation  of  antagonistic  muscles.  Tremors 
are  observed  in  the  following  conditions  : — 

1.  They  may  exist  from  birth  unassociated  with  other 
symptoms. 

2.  They  may  depend  upon  a  lowered  tone  of  the  nervous 
system,  being  frequently  observed  in  neurasthenia  and  in  the 
convalescence  from  acute  disease. 

3.  They  may  be  toxic,  resulting  from  alcoholism  or  mer- 
curial poisoning. 

4.  They  may  be  due  to  old  age. 

5.  They  are  frequently  a  symptom  of  organic  disease  of  the 
brain  and  cord ;  as  such,  they  are  met  with  in  paretic  dementia, 
and  especially  in  disseminated  sclerosis. 

6.  They  may  be  the  chief  symptom  in  paralysis  agitans. 

7.  They  may  be  hysterical. 

The  Gait. 

The  Ataxic  Gait. — In  locomotor  ataxia  the  patient  raises 
the  foot  high,  throws  it  forward,  and  brings  it  down  suddenly, 
so  that  the  whole  sole  comes  in  contact  with  the  floor  at  once. 

Spastic  Gait. — In  spastic  paraplegia  the  movements  are 
stiif,  the  knees  come  together,  the  leg  drags  behind,  and  the 
toe  catches  the  ground. 

Festination. — This  term  is  applied  to  the  gait  of  advanced 
paralysis  agitans ;  in  walking,  the  body  inclines  more  and 
more  forward,  and  the  steps  grow  faster  and  faster  until  the 
patient  falls,  straightens  himself  by  an  effort,  or  finds  suj^port 
in  some  neighboring  object. 

Steppage  Gait. — In  chronic  multiple  neuritis  the  patient 
raises  the  foot  high,  turns  the  toe  up,  and  brings  the  heel  down 
first. 

The  Gait  of  Pseudo-muscular  Hypertrophy. — The  feet  are 
wide  apart,  the  belly  protrudes,  aud  the  movements  are  clumsy 
and  waddling. 


318  DISEASES   OF   THE  NERVOUS   SYSTEM. 

Titubation. — This  term  is  applied  to  the  peculiar  gait  ob- 
served in  lesioDS  of  the  cerebellurQ.  It  resembles  the  gait  of 
locomotor  ataxia,  but  is  much  more  staggering.  It  is  not  de- 
pendent upon  loss  of  coordination,  for  in  lying  down  the 
patient  can  perfectly  control  his  movements.  The  absence  of 
the  Argyll-Robertson  pupil,  of  sharp  pains,  and  of  diminished 
reflexes  will  separate  cerebellar  disease  from  locomotor  ataxia. 

The  Reflexes. 

The  "  tendon  reflexes"  were  formerly  thought  to  be  a  pure 
reflex  phenomenon,  but  the  tendency  at  present  is  to  regard 
them  as  resulting  from  the  contraction  of  the  muscle  itself. 
But  that  the  muscle  shall  contract,  it  must  receive  certain 
impulses  from  the  cord,  which  keep  it  in  a  condition  of  irrita- 
bility. It  follows,  therefore,  that  reflexes  are  dependent  upon 
the  condition  of  the  cord  as  well  as  of  the  muscles. 

The  Knee-jerkj  or  Patellar  Tendon  Reflex. — This  is  ob- 
tained by  tapping  the  quadriceps  tendon  between  its  insertion 
and  the  patella  while  the  leg  is  crossed  over  its  fellow. 

T/ie  hnee-jerh  is  increased  in  the  following  conditions  : — 

1.  Frequently  in  organic  disease  of  the  brain,  probably  from 
irritation  of  the  cord. 

2.  In  lesion  of  the  cord  above  the  lumbar  enlargement, 
probably  from  cutting  off  the  influence  of  the  reflex  inhibiting 
centre  in  the  upper  part  of  the  cord. 

3.  In  disseminated  cerebro-spinal  sclerosis  and  in  lateral 
sclerosis. 

4.  In  irritability  of  the  cord,  as  in  mania,  hysteria,  strych- 
nia-poisoning, and  spinal  meningitis. 

The  knee-jerk  is  diminished  or  absent  in  the  following  con- 
ditions : — 

1.  Degeneration  of  the  muscle,  as  in  pseudo-muscular  hy- 
pertrophy. 

2.  In  lesions  of  the  nerves  which  cut  off  the  impulse  from 
the  cord — as  neuritis. 

3.  In  lesion  of  the  posterior  columns  of  the  cord,  as  in  loco- 
motor ataxia. 

4.  In  poliomyelitis,  acute  and  chronic  (the  anterior  gray 
matter  is  part  of  the  reflex  centre). 


DISTURBANCES   OF   MOTION. 


319 


5.  In  advanced  myelitis,  when  the  cord  is  sufficiently 
injured. 

6.  In  exhaustion  of  the  spinal  centres,  as  after  prolonged 
laborious  work. 

7.  In  poisoning  from  drugs  which  depress  the  cord,  as  anti- 
mony, chloral,  etc. 

8.  In  certain  general  diseases,  as  diabetes  and  diphtheria. 
Ankle-clonus. — This     consists     of    vibratory    movements 

obtained  by  supporting  the  tendo- Achilles  with  one  hand,  while 
the  foot  is  strongly  flexed  with  the  other.  It  can  rarely  be 
obtained  in  health,  but  is  often  marked  in  hysteria  and  in 
lateral  sclerosis. 

Arm-jerk. — This  is  obtained  by  striking  the  biceps  tendon 
at  the  elbow,  or  the  triceps  tendon  above  the  olecranon. 

Jaw-jerk. — This  is  obtained  by  tapping  the  jaw  w^hile  the 
mouth  is  partially  open. 

The  Superficial  Reflexes. — These  are  probably  true  reflexes, 
and  consist  in  muscular  contractions  resulting  from  irritation 
of  the  skin. 

The  following  table  is  based  upon  the  description  given  by 
Ross  in  his  Handbook  of  Nervous  Diseases  : — 


The  Reflex. 
Plantar  . 

Gluteal  .  . 

Cremasteric 

Abdominal    . 
Epigastric    . 

Erector  Spinal 

Scapular      .     . 

Palmar    .     .     . 


Produced  by 

Tickling   the    sole   of    the 

foot. 
Stimulating  the  skin  over 

the  buttock. 
Stimulating   the    skin    on 

the   inner    side    of    the 

thigh. 
Stroking  the    skih  on  the 

side  of  the  abdomen. 
Stimulating    the    sides    of 

the  chest  in  the  fifth  and 

sixth  intercostal  spaces. 
Irritation    from   the  angle 

of  the    scapula    to    the 

iliac  crest. 
Irritation  of  the  scapular 

region. 


Tickling  the  palm. 


Depends  upon  Integrity  of 

The  lower  end  of  the  cord 
(conus  meduUaris). 

Loops  through  the  fourth 
and  fifth  lumbar  nerves. 

First  and  second  pairs  of 
lumbar  nerves. 

The  arcs  from  the  eighth  to 

the  twelfth  dorsal  nerves. 
The    arcs  from   the  fourth 

to   the  seventh  pairs  of 

dorsal  nerves. 
The    arcs     in    the    dorsal 

region  of  the  cord. 

The  arcs  of  the  upper  two 
or  three  dorsal  and  the 
lower  two  or  three  cervi- 
cal nerves. 

The  arcs  through  the 
greater  part  of  the  cervi- 
cal enlargement. 


320  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  chief  cranial  reflexes  are  contraction  of  the  palatal 
muscles  by  irritation  of  the  fauces  ;  sneezing,  by  irritation  of 
the  nares ;  cough,  by  irritation  of  the  larynx  ;  closure  of  the 
eyelids,  by  irritation  of  the  conjunctiva;  and  contraction  of 
the  iris,  by  light. 

Paradoxical  Contraction.  (Westphal.) — This  is  a  peculiar 
phenomenon  consisting  of  a  tetanic  contraction  of  the  tibialis 
anticus,  lasting  for  several  minutes,  and  induced  by  forcibly 
flexing  the  foot  on  the  leg.  Its  cause  is  unknown.  It  has 
been  observed  in  early  locomotor  ataxia,  multiple  sclerosis, 
hysteria,  and  paralysis  agitans. 

DISTURBANCES  OF  SENSATION. 

These  consist  chiefly  in  a  loss  of  sensation — ancesthesia  ;  in- 
creased sensation — hypenesthesia  ;  certain  abnormal  sensations 
— jmroesthesia  ;  and  subjective  painful  sensations — neuralgia. 

Ansestliesia. 

Ordinary  cutaneous  sensibility  may  be  tested  by  the  prick 
of  a  pin,  by  a  pinch,  or  by  the  faradic  current. 

Anaesthesia  results  from  interruption  of  the  sensory  tract  in 
the  nerves,  as  by  neuritis ;  from  interruption  of  the  sensory 
tract  in  the  cord  or  brain  ;  from  organic  disease  of  the  sensory 
area  of  the  brain ;  from  the  action  of  toxic  substances  on  the 
nerves  or  centres;  from  certain  functional  conditions  like 
hysteria  ;  and  from  reflex  irritation. 

Hemiancesthesia. — A  loss  of  sensation  on  a  lateral  half  of 
the  body.     It  may  result  from  : — 

1.  Hysteria.  This  is  often  unassociated  with  paralysis  of 
motion,  and  may  be  recognized  by  the  history,  sex,  and  tem- 
perament of  the  patient ;  by  the  paroxysmal  character  of  the 
anesthesia ;  and  by  exclusion  of  other  causes. 

2.  A  unilateral  lesion  high  in  the  cord.  This  is  very  rare, 
and  may  be  recognized  by  being  associated  with  hemiplegia  on 
the  opposite  side. 

3.  A  lesion  of  the  medulla  (very  rare).  The  hemianses- 
thesia  is  usually  associated  with  hemiplegia,  paralysis  of  the 


DISTURBANCES  OF  SENSATION.  321 

cranial  nerves,  difficult  swallowing,  and  cardiac  and  respiratory 
disturbances. 

4.  A  lesion  in  the  pons.  The  hemiansesthesia  is  often 
associated  with  hemiplegia  on  the  same  side,  and  facial  palsy 
on  the  opposite  side. 

5.  A  lesion  in  the  crus,  or  peduncle.  The  hemiansesthesia 
is  often  associated  with  hemiplegia  on  the  same  side  and 
paralysis  of  the  oculomotor  nerve  on  the  opposite  side. 

6.  A  lesion  of  the  posterior  limb  of  the  internal  capsule,  or 
of  the  optic  thalamus  pressing  on  the  capsule. 

7.  A  lesion  of  the  occipital  cortex, 

Monancesthesia. — A  loss  of  sensation  in  one  member.  It 
may  result  from  hysteria,  from  a  focal  lesion  of  the  occipital 
cortex,  or  from  a  lesion  of  the  nerves  supplying  the  member. 

Pcvrancesthesia. — A  loss  of  sensation  in  all  parts  below  the 
waist.  It  may  result  from  hysteria,  organic  diseases  of  the 
cord,  neuritis  of  the  lower  extremities,  or  reflex  irritation. 

Thermo-ancesthesia. — Insensibility  to  heat  or  cold  occurring 
as  an  independent  condition.  It  is  sometimes  observed  in 
hysteria  and  syringo-myelia. 

Analgesia. — Insensibility  to  pain.  It  is  sometimes  observed 
in  hysteria,  in  syringo-myelia,  and  in  lesions  of  the  spinal 
cord. 

Retardation  of  Sensations. — This  is  frequently  observed  in 
all  forms  of  anaesthesia,  but  especially  in  the  anaesthesia  of  loco- 
motor ataxia. 

I7ie  Sense  of  Pressure, — This  is  tested  by  blocks  of  wood 
loaded  with  lead,  of  diiferent  weights,  the  arm  being  held  on 
a  table  so  as  to  exclude  the  muscular  sense.  Partial  paralysis 
of  this  sense  is  often  noted  in  locomotor  ataxia. 

The  Sense  of  Space. — The  distance  at  which  two  points  of 
contact  can  be  recognized  as  two  points.  Normally  the  dis- 
tance varies  in  different  parts  and  in  different  individuals. 

On  the  cheek  it  is  11-15  millimeters. 

On  the  forehead,  22  millimeters. 

On  the  forearm,  40  millimeters. 

On  the  chest,  45  millimeters. 

On  the  thigh,  77  millimeters. 

On  the  leg,  40  millimeters. 
21 


322  DISEASES   OF   THE  NERVOUS  SYSTEM. 

On  the  palm  of  the  hand,  8-12  millimeters. 

On  the  back  of  the  hand,  31  millimeters. 

HyperSBSthesia  is  increased  sensibility  to  external  impres- 
sions. 

It  is  commonly  observed  in  hysteria,  especially  in  connection 
with  the  joints,  breasts,  genitalia,  and  spine.  It  is  also  ob- 
served in  neurasthenia,  and  in  beginning  inflammation  of  the 
nerves  and  of  the  cerebro-spinal  meninges. 

Farsesthesia. — This  term  is  used  to  indicate  certain  disa- 
greeable subjective  phenomena,  such  as  numbness,  tingling, 
itching,  creeping,  and  "  pins  and  needles." 

Parsesthesia  is  observed  in  many  conditions,  as  hysteria, 
spinal  sclerosis,  neurasthenia,  and  injury  or  inflammation  of 
the  nerves. 

Gii'dle  Sensation. — The  sense  of  having  a  girdle  or  tight  band 
around  the  trunk.     It  is  frequently  observed  in  spinal  sclerosis. 

Neuralgia. — This  consists  of  paroxysms  of  severe  pain 
radiating  along  the  line  of  the  nerve-trunks.  The  pain  is  re- 
lieved by  pressure,  but  there  are  tender  spots  {points  doulou- 
reux) where  the  nerve  makes  its  exit  from  bony  canals  or 
muscular  coverings. 

Lightning-pains. — This  term  is  applied  to  the  sharp  lancinat- 
ing pains  observed  in  locomotor  ataxia.  They  usually  occur 
in  the  extremities,  and  may  be  mistaken  for  rheumatism. 

Causalgia. — This  term  has  been  applied  by  S.  Weir  Mit- 
chell to  an  intensely  burning  sensation  generally  observed  in 
"glossy  skin." 

Muscular  Sensibility. — This  term  is  applied  to  the  appreci- 
ation of  the  sensation  which  attends  the  contraction  of  a  muscle 
under  the  faradic  current. 

Muscular  Sense. — This  is  the  sense  by  which  weight,  mus- 
cular effort,  and  position  are  determined.  It  is  often  defective 
in  hysteria,  locomotor  ataxia,  and  in  many  forms  of  paralysis. 

distiirba:nces  of  nutrition. 

These  consist  in  atrophy  of  the  muscles,  changes  in  electro- 
muscular  contractility,  tissue-metamorphoses,  and  in  certain 
abnormalities  of  the  appendages. 


DISTUEBAISrCES   OP   NUTRITION.  323 

Muscular  Atrophy. 

Atrophy,  or  wasting  of  the  muscles  results  from : — 

1.  Inactivity.  Cerebral  palsies  may  thus  be  associated  with 
slow  wasting. 

2.  Lesions  of  the  trophic  cells  in  the  anterior  gray  horns  of 
the  cord,  as  in  acute  and  chronic  poliomyelitis. 

3.  Lesions  of  the  nerves,  such  as  neuritis  or  traumatism. 

4.  Certain  diseases  of  the  muscles  themselves,  as  idiopathic 
muscular  atrophy. 

The  atrophy  which  attends  chronic  affections  of  the  joints 
probably  results  from  neuritis. 

The  Reaction  of  Degeneration. 

In  muscular  paralysis  there  may  be  simply  diminished  elec- 
trical excitability.  This  is  termed  a  quantitative  change.  In 
some  cases,  however,  there  is  a  complete  reversal  of  the  normal 
phenomena.  This  is  termed  a  qualitative  change,  or  the  reaction 
of  degeneration. 

The  reactions  of  degeneration  are  obtained  with  the  galvanie 
current  applied  to  muscles  in  the  advanced  stage  of  degeneration . 

The  subjoined  table,  setting  forth  the  electro-muscular 
phenomena  in  health  and  disease,  follows  closely  the  description 
ofH.  C.Wood:— 

The  anode — the  positive  pole  ;  the  cathode — the  negative 
pole.  When  a  galvanic  current  of  moderate  strength  is  em-  ♦ 
ployed,  and  the  cathode  is  placed  over  the  normal  muscle,  a 
strong  contraction  occurs  when  the  circuit  is  closed ;  when  the 
anode  is  placed  over  the  muscle  the  contraction  is  much  less  ; 
in  neither  case  is  there  any  contraction  when  the  current  is 
broken.  When  a  strong  current  is  used  contractions  are  pro- 
duced, and  the  anodal  contraction  is  greater  than  the  cathodal. 
The  reaction  of  degeneration  consists  in  a  reversal  of  these 
phenomena. 


324  DISEASES  OF  THE   NEKVOUS  SYSTEM. 


Normal  muscle. 

A  nodal  closing  contraction  (AnClC)  is  less  than  the  catho- 
dal closing  contraction  (CaClC). 

Auodal  opening  contraction  (AnOC)  is  greater  than  the 
cathodal  opening  contraction  (CaOC). 

Muscle  in  first  stage  of  degeneration. 

Anodal  closing  conti-action  (AnClC)  equals  the  cathodal 
closing  contraction  (CaClC). 

Auodal  opening  contraction  (AnOC)  equals  the  cathodal 
opening  contraction  (CaOC). 

Muscle  in  advanced  stage  of  degeneration. 

Anodal  closing  contraction  (AnClC)  is  greater  than  the 
cathodal  closing  contraction  (CaClC). 

Anodal  opening  contraction  (AnOC)  is  less  than  the  cathodal 
opening  contraction  (CaOC). 

The  reactions  of  degeneration  are  observed  in  diseases  which 
destroy  the  trophic  cells  in  the  anterior  gray  horns  of  the  cord 
or  which  cut  oiF  their  influence.  Thus  they  are  observed  in 
acute  and  advanced  chronic  poliomyelitis,  in  acute  central  mye- 
litis, in  severe  neuritis,  and  after  section  or  compression  of  the 
nerves. 

Arthropathies. 

An  arthropathy  is  a  degenerative  affection  of  the  joints, 
characterized  by  marked  swelling  due  to  effusion,  erosion  of 
the  cartilages,  relaxation  and  calcification  of  the  ligaments,  and 
atrophy  of  the  heads  of  the  bones.  Arthropathies  are  observed 
especially  in  locomotor  ataxia  and  in  cerebral  hemiplegia. 
Some  regard  the  joint-phenomena  of  rheumatoid  arthritis  as 
belonging  to  this  class. 

Myxoedema. 

Myxoedema  consists  of  an  overgrowth  of  mucoid  tissue  in 
the  subcutaneous  tissues ;  it  occurs  as  an  idiopathic  affection ; 


DISTURBANCES   OF  CONSCIOUSNESS.  325 

sometimes  after  the  removal  of  the  thyroid  gland ;  and  as  a 
symptom  of  cretinism. 

Ulceration  Resulting  from  Perverted 
Nutrition. 

Aeiite  Decubitus. — This  term  is  applied  to  ulcers  appearing 
in  a  few  hours  or  days,  on  parts  subjected  to  pressure,  after  the 
occurrence  of  a  severe  cerebral  or  spinal  lesion. 

Chronic  Decubitus. — This  term  is  applied  to  the  ulcers  which 
ultimately  appear  on  parts  subjected  to  pressure  in  the  course 
of  chronic  spinal  affections. 

Perforating  Ulcer  of  the  Foot. — This  term  is  applied  to  ;in 
undermining  ulcer  of  the  foot  most  commonly  observed  in 
locomotor  ataxia.  It  frequently  penetrates  the  deep  structures 
and  involves  the  bones. 

Symmetrical  Gangrene  {Raynaud's  Disease). — This  is  a  gan- 
grenous affection  involving  the  fingers,  toes,  tip  of  the  nose, 
or  ears.  It  arises  spontaneously,  and  is  probably  due  to  a 
vaso-motor  spasm. 

Trophic  Affections  of  the  Skin.  —  Herpes,  scleroderma, 
vitiligo,  chloasma,  and  the  "glossy  skin"  following  injuries 
of  the  nerve-trunks,  are  illustrations  of  this  class  of  trophic 
phenomena. 

Trophic  Affections  of  the  Hair  and  Nails. — After  injury  of 
the  nerves  and  in  neuritis  the  nails  often  become  dry,  brittle, 
and  cracked.  Under  similar  conditions  there  may  be  a  loss  of 
hair,  an  overgrowth  of  hair,  or  a  change  in  the  color  of  the 
hair. 

DISTURBANCES  OF  CONSCIOUSNESS. 
Coma. 

Coma  is  a  condition  of  unconsciousness  from  which  the 
patient  cannot  be  aroused. 

Temporary  unconsciousness,  due  to  anaemia  of  the  brain, 
is  termed  syncope,  which  may  be  recognized  by  the  extreme 
pallor,  weak  pulse,  and  feeble  heart-sounds. 


326  DISEASES   OF  THE   NERVOUS  SYSTEM. 

1.  Coma  may  result  from  traumatism.  This  can  only  be 
recognized  by  the  history  or  the  local  evidence  of  injury. 

2.  Organic  Disease  of  the  Brain. — The  most  common  cause 
under  this  head  is  apoplexy,  which  may  be  recognized  by  the 
history,  the  age,  the  condition  of  the  arteries,  and  by  evidences 
of  paralysis,  such  as  unnatural  relaxation  or  rigidity  on  one 
side  of  the  body,  conjugate  deviation  of  the  eyes,  or  a  higher 
temperature  in  one  axilla. 

3.  Epilepsy. — The  coma  of  epilepsy  is  usually  of  short  dura- 
tion. It  may  be  recognized  by  the  history,  by  the  bloody 
saliva,  by  the  presence  of  scars  on  the  tongue  from  previous 
attacks,  and  by  the  exclusion  of  other  causes. 

4.  Thermic  Fever  (Sunstroke). — The  temperature  of  the  day 
or  of  the  room  in  which  the  patient  is  found,  the  extremely 
high  body-temperature,  and  the  absence  of  other  causes  will 
usually  prevent  an  error  in  diagnosis. 

5.  Certain  Drugs. — Under  this  head  come  alcoholism  and 
opium-poisoning.  In  alcoholism  the  patient  can  generally  be 
aroused  by  shouting  in  the  ear,  there  is  the  odor  on  the  breath, 
and  there  is  an  absence  of  other  cause. 

In  opium-poisoning  the  pupils  are  small,  the  respirations 
are  slow,  the  temperature  is  normal  or  subnormal ;  there 
may  be  the  odor  of  laudanum  on  the  breath.  The  diagnosis 
will  be  aided  by  the  exclusion  of  other  causes. 

6.  Urcemia. — In  this  condition  there  is  a  urinous  odor  on 
the  breath  ;  the  aortic  second  sound  is  accentuated ;  the  urine 
contains  albumin ;  the  temperature  may  be  above  or  below 
normal ;  the  pupils  are  usually  small,  and  there  is  no  evidence 
of  other  cause. 

7.  The  Infectious  Fevers. — The  history  is  sufficient  to  make 
the  diagnosis.  Pernicious  malarial  fever  may  produce  sudden 
coma,  and  in  this  condition  the  examination  of  the  blood 
would  render  a  diagnosis  possible. 

8.  Hysteria. — The  history,  age,  and  sex  of  the  patient,  and 
the  absence  of  other  cause  will  suggest  the  condition. 

9.  Acetonmnia. — Diabetic  coma  may  be  recognized  by  the 
history,  the  sweetish  odor  of  the  breath,  the  glycosuria,  and 
the  subnormal  temperature. 


DISTURBANCES   OF  THE  SPECIAL   SENSES.  327 

Trance. 

In  this  condition  the  patient  lies  for  several  days  apparently- 
dead,  the  pulse  and  respiration  being  imperceptible.  It  is 
usually  a  manifestation  of  hysteria. 

Somnambulism. 

A  dreamlike  state,  in  which  the  patient  performs  auto- 
matically various  feats- — such  as  walking,  singing,  writing,  etc. 
Mild  forms,  such  as  talking  and  walking  in  sleep,  may  occur 
in  health.  More  marked  manifestations  occur  in  hysteria  and 
in  hypnotism.  * 

Ecstasy. 

A  condition  of  apparent  insensibility  in  which  the  mind  is 
wholly  absorbed  with  a  fancy  or  delusion.  It  occurs  in  the 
hysterical.  The  dancing  mania  of  the  middle  ages  is  a  good 
illustration  of  it. 

Catalepsy. 

This  term  is  applied  to  attacks  characterized  by  a  peculiar 
stiffness  of  the  muscles,  and  when  this  is  overcome  by  force 
the  limbs  can  be  placed  in  unnatural  positions,  which  they 
retain  for  a  long  time.  There  may  or  may  not  be  a  loss  of 
consciousness  and  sensation.  It  is  observed  in  hysteria,  hyp- 
notism, in  some  cases  of  epilepsy,  in  some  organic  diseases  of 
the  brain,  and  in  certain  forms  of  insanity — notably  katatonia. 

DISTURBANCES  OF  THE  SPECIAL.  SENSES. 
The  Eye. 

Myosis. — Contraction  of  the  pupil  occurs  in  many  condi- 
tions, notably  in  locomotor  ataxia,  paretic  dementia,  some 
cases  of  disseminated  sclerosis,  old  age,  uraemia,  and  opium- 
poisoning. 

Mydriasis. — Dilatation  of  the  pupil  is  also  observed  in 
many  conditions,    notably  in   atrophy   of   the   optic    nerve, 


328  DISEASES   OF   THE   NERVOUS   SYSTEM. 

paralysis  of  the  third  nerve,  collapse,  severe  pain,  epileptic 
seizures,  hysterical  attacks,  belladonna-poisoning,  and  in  some 
cases  of  locomotor  ataxia  and  paretic  dementia. 

Inequality  of  the  Pupils. — This  may  occur  in  health,  in 
ocular  defects,  in  organic  brain  disease,  in  paretic  dementia, 
in  locomotor  ataxia,  in  aneurism  pressing  on  the  cervical  sym- 
pathetic, and  in  unilateral  paralysis  of  the  oculo-motor  nerve. 

Argyll-Robertson  Pupil. — This  is  one  which  fails  to  respond 
to  light,  but  still  accommodates  for  distance.  It  is  noted  espe- 
cially in  locomotor  ataxia  and  paretic  dementia. 

Conjugate  Deviation  of  the  Eyes. — This  term  is  applied  to 
the  rotation  of  both  eyes  away  from^  the  median  line.  It  is 
noted  especially  in  apoplexy  and  in  convulsions  of  organic 
brain  disease. 

Nystagr)ius  {Tremor  of  the  Eyeball.) — It  may'  be  con- 
genital, associated  with  certain  ocular  troubles,  or  due  to 
disease  of  basal  ganglia,  especially  disseminated  sclerosis. 

The  Ear. 

Tinnitus  Aurium  {Noises  in  the  Ear). — They  are  observed 
in  cerebral  hypersemia  and  anaemia,  in  diseases  of  the  ear,  in 
Meniere's  disease,  and  after  the  use  of  certain  drugs  like 
quinine  and  salicylic  acid. 

Hyperacusis  of  Hearing. — This  is  sometimes  observed  in 
Iiysteria,  in  facial  paralysis,  and  in  cerebral  hypersemia. 

Deafness  generally  depends  upon  disease  of  the  ear  itself. 

PSYCHICAL  DISTURBANCES. 

Delusion. — A  delusion  is  a  faulty  belief  concerning  a  subject 
capable  of  physical  demonstration,  out  of  which  the  person 
cannot  be  reasoned  by  adequate  methods  for  the  time  being. 
(Wood.) 

A  systematized  delusion  is  one  which  the  patient  endeavors 
to  defend  by  a  process  of  reasoning  more  or  less  logical.  Sys- 
tematized delusions  are  especially  observed  in  monomania. 

An  unsystematized  delusion  is  one  which  the  patient  makes 
no  attempt  to  justify  ;  he  asserts  his  belief  without  reason. 


PSYCHICAL   DISTURBANCES.  329 

The  majority  of  delusions  are  unsystematized";  and  as  such  are 
observed  in  most  forms  of  insanity. 

A  fixed  delusion  is  one  which  the  patient  retains  for  a  con- 
siderable length  of  time  ;  it  is  frequently  systematized.  Fixed 
delusions  are  observed  in  monomania,  paretic  dementia,  hys- 
terical insanity,  and  sometimes  in  melancholia. 

An  expansive  delusion,  or  a  delusion  of  grandeur,  is  one 
which  exalts  its  possessor.  The  patient  conceives  that  he  is 
some  noted  personage,  that  he  is  worth  millions  of  dollars,  or 
that  he  is  capable  of  performing  certain  marvellous  feats.  Ex- 
pansive delusions  are  frequently  observed  in  paretic  dementia, 
mania,  and  hysterical  insanity. 

A  hypochondriaeal  delusion  is  one  which  depresses  its 
possessor.  The  patient  believes  that  he  has  committed  the 
unpardonable  sin,  that  he  is  being  persecuted,  or  that  he  is 
the  victim  of  some  dread  disease.  Hypochondriacal  delusions 
are  frequently  observed  in  melancholia,  alcoholic  insanity,  and 
in  some  cases  of  monomania  and  paretic  dementia. 

Illusion. — An  illusion  is  a  perverted  perception.  Thus  in 
delirium  tremens  the  patient  may  transform  every  piece  of 
furniture  into  a  demon  or  reptile. 

Halluciliation.  —  An  hallucination  is  a  false  perception, 
entirely  subjective,  and  not  based  upon  any  knowledge  derived 
from  without.  An  individual  who  hears  voices  and  sees  ob- 
jects when  none  exist  is  the  subject  of  hallucinations. 

Imperative  Conception. — A  conception  which  the  person 
knows  to  be  false,  but  which,  nevertheless,  dominates  his 
thoughts  and  often  directs  his  actions.  When  he  fails  to 
recognize  the  falsity  of  his  conception,  it  becomes  a  delusion. 
A  morbid  impulse  is  an  irresistible  desire  to  commit  an  act 
which  the  patient  knows  to  be  wrong.  It  is  usually  the  result 
of  an  imperative  conception. 

Kleptomania  is  a  morbid  desire  to  steal.  Pyromania  is  a 
morbid  desire  to  set  fire  to  buildings. 

Delirium. 

Delirium  is  a  mental  state  characterized  by  a  rapid  flight  of 
ideas  which  are  incoherent  and  often  unintelligible.  It  may 
result  from  : — 


330  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Acute  Delirium  {BelVs  Mania). — A  disease  arisiug  without 
obvious  cause,  and  characterized  by  an  abrupt  onset,  active 
delirium,  a  constant  repetition  of  certain  phrases  or  acts, 
moderate  fever,  often  a  bullous  eruption,  and  exhaustion.  It 
generally  ends  fatally  in  the  course  of  a  few  weeks. 

Mania. — ^In  this  affection  the  onset  is  not  abrupt.  Symp- 
toms of  impaired  health  and  mental  depression,  covering  a 
period  of  several  weeks  or  months,  generally  precede  the  out- 
break of  the  delirium. 

Hysteria. — The  history,  age,  sex,  and  temperament,  and  the 
intermittent  character  of  the  delirium  will  aid  in  the  diagnosis. 

One  of  the  Infectious  Fevers. — Pneumonia  and  typhoid  fever 
are  especially  liable  to  be  associated  with  delirium.  The 
physical  signs  in  the  former  and  the  abdominal  symptoms  in 
the  latter  will  usually  indicate  the  diagnosis. 

Unemia. — The  urinous  odor  of  the  breath,  the  high  arterial 
tension,  the  accentuation  of  the  second  aortic  sound,  and  the 
presence  of  albumin  and  casts  in  the  urine  will  suggest  uraemia. 

Alcoholism. — The  history,  the  appearance  of  the  patient,  the 
marked  tremors,  and  frequently  terrifying  hallucinations  will 
indicate  alcoholism. 

Inanition. — A  form  of  delirium  occasionally  arises  in  the 
course  of  exhausting  diseases.  It  is  associated  with  pallor, 
feeble  pulse,  and  cold  extremities.  It  is  generally  of  short 
duration,  and  may  be  recognized  by  the  circumstances  under 
which  it  develops. 


TUBERCULAR   MENnSTGITIS.  331 

TUBERCULOUS  ]\IENrPfGITIS. 

(Basilar  Meningitis,  Acute  Hydrocephalus.) 

Definition. — An  acute  inflammation  of  the  cerebral  men- 
inges excited  by  the  tubercle  bacillus. 

Etiology. — In  children  the  disease  may  be  primary,  but 
in  adults  it  is  always  secondary  to  a  primary  focus  of  tuber- 
culosis in  some  other  part  of  the  body.  The  majority  of  cases 
are  observed  between  the  second  and  the  fifth  years.  Heredity, 
bad  hygienic  surroundings,  and  poor  food  (milk  from  a  tuber- 
culous mother)  are  predisposing  factors. 

Pathology. — The  basilar  meninges  are  especially  involved. 
The  pons,  crura,  and  medulla  are  covered  with  soft  lymph 
which  mats  together  in  a  common  mass  the  adjacent  nerves 
and  bloodvessels.  The  tuberculous  character  of  the  inflam- 
mation is  manifested  by  the  presence  of  small  yellowish 
nodules  which  are  particularly  abundant  along  the  bloodvessels 
in  the  Sylvian  fissures.  The  amount  of  fluid  in  the  ventricles 
is  increased,  and  the  ependyma  is  soft  and  cedematous.  The 
cortical  substance  underlying  the  affected  meninges  is  also 
soft  and  infiltrated  with  leucocytes. 

Symptoms. — ^The  disease  usually  begins  insidiously  with 
certain  prodromal  symptoms.  The  disposition  of  the  child 
changes  ;  he  ceases  to  play  ;  he  becomes  dull  and  listless,  and 
when  disturbed,  irritable.  Sleep  is  broken  and  fitful ;  the 
child  twitches,  grinds  his  teeth,  or  starts  up  with  a  cry  of 
alarm.  Headache  develops,  and  is  soon  associated  with  fever 
and  vomiting ;  the  tongue  is  coated  ;  the  appetite  lost ;  and 
the  bowels  constipated.  When  the  disease  is  fully  developed 
the  headache  becomes  intense,  and  frequently  causes  from  time 
to  time  a  shrill  scream  —  the  "  hydrocephalic  cry."  The 
special  senses  are  abnormally  acute,  so  that  bright  lights  and 
loud  sounds  cannot  be  tolerated.  The  surface  is  also  hyperees- 
thetic,  and  when  touched,  the  child  becomes  extremely 
irritable.  The  temperature  is  moderately  high  (102°-103°) ; 
the  pulse  is  at  first  rapid,  but  later  slow  and  irregular  ;  the 
abdominal  walls  are  retracted  ;  the  muscles  of  the  neck  rigid  ; 
and  the   pupils  contracted.     Convulsive  seizures   frequently 


332  DISEASES   OF  THE   NEEVOUS  SYSTEM. 

develop ;  they  may  be  general  or  local.  The  child  lies  on 
one  side  with  the  limbs  drawn  up,  the  head  strongly  retracted, 
and  the  fingers  clinched  over  the  thumb,  which  is  turned 
into  the  palm.  Towards  the  close  of  this  stage  delirium 
develops. 

When  the  exudate  is  sufficient  in  amount  to  exert  marked 
pressure,  paralytic  phenomena  develop.  Local  palsies,  espe- 
cially of  the  facial  muscles,  take  the  place  of  convulsions ; 
coma  follows  delirium  ;  the  pupils  dilate  and  tlie  eyes  roll  up ; 
photophobia  is  replaced  by  blindness,  and  intolerance  of 
sound  by  deafness.  If  the  finger  is  drawn  across  the  body, 
a  bright  red  line  develops  and  lingers  for  some  minutes;  this 
is  the  tdehe  cerebrale  of  Trousseau.  The  pulse  now  becomes 
rapid  and  irregular ;  the  respiration  assumes  the  Cheyne- 
Stokes  type,  and  the  temperature  falls.  The  duration  is  from 
one  to  three  weeks. 

Diagnosis.  Typhoid  Fever.— l^yi^\vo\(\.  fever  may  closely 
simulate  meningitis,  especially  in  the  young ;  but  the  early 
development  of  cerebral  symptoms,  the  irregular  fever,  the 
slow  pulse  of  the  first  stage,  the  retracted  abdominal  walls, 
the  constipation,  and  the  absence  of  rose-colored  spots  will 
serve  to  distinguish  meningitis  from  typhoid  fever. 

Simple  Meningitis. — An  absolute  diagnosis  may  be  impos- 
sible, but  the  history  of  tuberculosis  in  the  family,  the  presence 
of  tuberculous  foci  in  other  parts,  the  detection  of  tubercle  on 
the  retina,  and  an  onset  without  obvious  cause  will  generally 
indicate  the  true  nature  of  the  case. 

Prognosis. — Absolutely  unfavorable. 

Treatment. — The  patient  should  be  placed  in  a  quiet, 
dark,  well-ventilated  room.  The  diet  should  be  liquid.  An 
ice-bag  should  be  applied  to  the  head.  Constipation  should 
be  relieved  by  enemata.  For  the  headache,  restlessness,  and 
convulsions,  chloral  and  bromide  of  potassium  are  useful,  and 
may  be  given  by  the  rectum. 

^   Moschi,  gr.  iij  ; 
Camphoree,  gr.  xv ; 
Chloral,  hydrat.,  gr.  viiss  ; 
Titelll  ovi,  No.  i ; 
Aq.  destillat.,  f.^iv.— M.     (Simon.) 
Sig. — Wash  out  the  rectum  with  a  simple  enema  and  inject  two 
ounces. 


CHRONIC  PACHYMENINGITIS.  333 

The  administration  of  ergot  and  of  iodide  of  potassium,  and 
the  external  application  of  an  ointment  of  iodoform  to  the 
shaved  scalp  have  been  recommended,  but  generally  prove 
useless. 

SIMPLE  LEPTO:»IE]NT]N^GITIS. 

(Acute  Leptomeningitis,  Meningitis  of  the  Convexity.) 

Definition. — An  acute  inflammation  of  the  pia  mater 
not  due  to  tubercle. 

Etiology. — Traumatism,  sunstroke,  rheumatism,  Bright's 
disease,  and  the  infectious  fevers,  are  the  usual  predisposing 
causes.  It  occasionally  develops  from  caries  of  the  bone  which 
is  secondary  to  middle-ear  disease. 

Pathology. — The  membranes  are  opaque,  thickened,  con- 
gested, adherent,  and  more  or  less  infiltrated  with  purulent 
fluid.  Generally  the  convexity  is  affected,  but  in  some  cases, 
as  those  following  middle-ear  disease,  the  base  is  chiefly  in- 
volved. The  adjacent  cortical  substance  is  also  oedematous, 
soft,  and  injected. 

Symptoms. — Moderate  irregular  fever,  loss  of  appetite,  con- 
stipation, intense  headache,  intolerance  to  light  and  sound, 
contracted  pupils,  delirium,  retraction  of  the  head,  convulsions, 
and  coma. 

When  the  base  is  involved,  the  symptoms  are  almost  identi- 
cal with  those  of  tuberculous  meninaritis. 

Prognosis. — Unfavorable,  though  recovery  is  not  im- 
possible. 

Treatment. — The  patient  should  be  placed  in  a  quiet, 
dark,  well- ventilated  room.  An  ice-bag  should  be  applied  to 
the  head.  AVhen  the  patient  is  robust,  wet  cups  or  leeches  may 
be  applied  to  the  neck.  The  diet  must  be  liquid.  Constipa- 
tion should  be  relieved  by  enemata.  Restlessness,  headache, 
and  convulsions  call  for  chloral  and  bromide  of  potassium. 

CHRONIC  PACHYMENINGITIS. 

Definition. — Inflammation  of  the  dura  mater. 
Etiology. — Inflammation  of  the  external  layer  may  result 
from  injury,  syphilis,  sunstroke,  or  caries  of  the  bone.     In- 


334  DISEASES   OF   THE   NERVOUS   SYSTEM. 

flammatiou  of  the  internal  layer  (hemorrhagic  pachymeningitis) 
may  be  secondary  to  chronic  cardiac  or  renal  disease,  one  of 
the  infectious  fevers,  chronic  alcoholism,  or  especially,  insanity. 

Hemorrhagic  Pachymeniugitis. 

(Haematoma  of  the  Dura  Mater.) 

Pathology. — The  membranes  are  thickened,  opaque,  and 
more  or  less  adherent.  The  bloodvessels  are  dilated.  Be- 
tween the  membranous  layers  are  frequently  observed  hemor- 
rhagic eifusions  ;  these  vary  in  extent  from  slight  ecchymoses 
to  clots  as  large  as  a  hen's  egg.  In  some  cases  the  pressure  of 
the  clots  on  the  convolutions  is  sufficient  to  cause  the  latter  to 
atrophy. 

Symptoms. — Often  obscure.  In  some  cases  there  are  no 
manifestations  during  life.  When  the  condition  is  marked, 
the  following  phenomena  may  be  observed  :  Headache,  failure 
of  memory,  impairment  of  intellect,  stupor,-  contracted  pupils, 
local  convulsions,  or  palsies.  The  symptoms  may  alternately 
improve  and  grow  worse  for  a  long  period.  In  grave  cases, 
associated  with  extensive  hemorrhagic  effusion,  the  symptoms 
resemble  apoplexy. 

Diagnosis. — This  can  rarely  be  made  with  certainty. 

Prognosis. — Unfavorable. 

Treatment. — Grave  cases  should  be  treated  as  apoplexy. 

HYDEOCEPHAJLUS. 

(Congenital  Hydrocephalus,  Water  on  the  Brain.) 

Definition. — A  condition  in  which  there  is  an  excessive 
accumulation  of  fluid  in  the  ventricles  or  arachnoid  cavity. 

Etiology. — Acquired  Hydrocephahts  may  develop  at  any 
period  of  life,  and  may  result  from  meningitis,  the  pressure  of 
a  tumor,  or  from  one  of  the  causes  of  general  dropsy. 

Congenital  Hydrocephalus,  the  form  now  under  discussion, 
dates  from  birth"^or  develops  in  the  first  few  years  of  life.  Its 
cause  is  unknown  ;  in  some  cases  it  is  probably  due  to  a  latent 
inflammation  of  the  ependyma  of  the  ventricles. 


HYDEOCEPHALUS.  335 

Pathology. — The  head  is  large  and  round ;  the  bones  are 
thin  and  translucent ;  the  sutures  and  fontanelles  are  enlarged, 
and.  if  life  has  been  prolonged,  are  iilled  with  numerous 
Wormian  bones.  The  convolutions  of  the  brain  are  flattened 
and  the  sulci  more  or  less  obliterated.  In  external  hydro- 
cephalus the  accumulation  of  fluid  is  found  in  the  arachnoid  sac; 
but  in  internal  hydrocephalus — the  most  common  form — the 
ventricles  are  greatly  distended  with  a  watery  fluid  of  low 
specific  gravity,  containing  a  trace  of  albumin.  The  epen- 
dyma  is  often  thickened  and  roughened.  Malformations  are 
frequently  observed,  and  probably  result  from  the  same  cause 
which  induced  the  eflPusion. 

Symptoms. — Sometimes  the  disease  develops  before  birth, 
and  the  large  head  interferes  with  the  delivery  of  the  child. 
In  other  cases  nothing  peculiar  is  observed  until  the  child  is 
several  months  old,  when  the  swelling  of  the  head  attracts 
the  attention  of  the  parents.  The  head  assumes  a  globular 
shape ;  the  fontanelles  and  sutures  remain  open  ;  the  face  be- 
comes relatively  small ;  the  eyes  protrude  and  are  directed 
downward  from  the  pressure  of  the  fluid  on  the  supraorbital 
plates ;  the  scalp  appears  thin  and  stretched ;  the  superficial 
veins  are  distended ;  and  the  hair  becomes  scant.  In  some 
cases  the  head  is  so  heavy  that  the  thin  neck  can  no  longer 
support  it,  and  it  falls  forward  on  the  breast. 

As  a  rule,  the  intelligence  is  considerably  impaired,  but  ex- 
ceptional cases  are  marked  by  precociousness.  Motor  phe- 
nomena are  frequently  present :  the  reflexes  are  exaggerated ; 
one  or  more  of  the  members  may  be  the  seat  of  a  spastic 
paralysis  ;  convulsions  develop  in  many  cases. 

The  duration  varies  in  different  cases.  The  large  majority 
soon  die  of  inanition,  convulsions,  or  some  intercurrent  disease 
to  which  their  reduced  vitality  makes  them  an  easy  prey ;  but 
in  a  few,  life  is  prolonged  for  many  years. 

Diagnosis. — Hydrocephalus  must  not  be  mistaken  for 
rachitic  enlargement  of  the  head.  In  the  latter,  the  head  is 
square  instead  of  globular ;  the  intelligence  is  good ;  there  are 
no  motor  phenomena;  and  bony  enlargements  are  usually 
detected  at  the  ends  of  the  long  bones  and  at  the  junction  of 
the  cartilages  with  the  ribs. 


336  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Prognosis. — Unfavorable.  In  a  few  cases  arrest  of  the 
disease  has  been  spontaneous,  or  has  resulted  from  aspiration 
of  the  fluid. 

Treatment. — The  treatment  is  unsatisfactory.  Counter- 
irritation  and  the  use  of  diuretics  and  absorbents  exert  no 
influence  on  the  disease.  In  the  majority  of  cases,  beyond 
dietetic  and  hygienic  measures  and  the  occasional  use  of  tonics, 
little  can  be  recommended.  In  cases  where  the  pressure- 
symptoms  are  marked,  tapping  offers  some  hopes  of  tem- 
porary relief.  After  the  operation  compression  of  the  skull 
should  be  made  by  the  application  of  concentric  bauds  of 
adhesive  plaster. 

PARETIC  DEMENTIA. 

(General  Paralysis  of  the  Insane,  General  Paresis,  Chronic 
Meningo-encephalitis.) 

Definition. — A  chronic  inflammatory  affection  of  the 
cerebral  cortex,  characterized  by  a  change  of  disposition, 
failure  of  memory,  mental  exaltation,  delusions  of  grandeur, 
tremors,  epileptiform  seizures,  and  paralysis. 

Etiology. — Male  sex,  middle  life,  prolonged  mental  strain, 
and  excesses  are  predisposing  factors.  It  may  be  induced  by 
the  usual  causes  of  sclerosis,  namely,  syphilis,  alcoholism,  lead- 
poisoning,  gout,  etc. 

Pathology, — The  membranes  are  opaque,  thickened,  and 
at  places,  adherent  to  the  brain  substance.  The  cortex  is  more 
or  less  atrophied  and  increased  in  firmness.  Microscopic 
examination  reveals  an  overgrowth  of  connective  tissue  and 
degeneration  of  nerve-fibres  and  ganglionic  cells. 

In  some  cases  similar  degenerative  changes  are  observed  in 
the  posterior  and  lateral  columns  of  the  cord. 

Symptoms. — The  disease  usually  begins  insidiously  with  a 
change  in  disposition;  the  industrious  become  slothful;  the 
ambitious,  apathetic ;  the  chaste,  dissolute ;  the  liberal,  parsi- 
monious ;  the  complaisant,  churlish  ;  and  the  truthful,  false. 
The  energy  relaxes,  the  judgment  weakens,  and  the  memory 
fails.  As  the  faculties  become  impaired,  a  peculiar  egotism 
and  a  mental  exaltation  develop ;  the  patient  becomes  boastful, 


PARETIC   DEMENTIA.  337 

loquacious,  and  easily  provoked  to  furious  outbreaks.  The 
failure  of  memory  is  early  noted  in  writing,  by  the  use  of 
wrong  letters  and  the  suppression  of  syllables.  At  this  time 
motor  phenomena  may  be  observed  :  the  tongue  trembles  when 
it  is  protruded  ;  the  speech  is  slow,  hesitating,  and  indistinct ; 
the  pupils  are  often  unequal ;  and  the  gait  is  somewhat 
shuffling. 

The  most  characteristic  psychical  symptom  of  fully-de- 
veloped paretic  dementia  is  the  delusion  of  grandeur :  the 
patient  conceives  that  he  is  some  distinguished  personage,  that 
he  owns  acres  of  land,  or  that  he  is  the  inventor  of  some 
wonderful  machine.  The  mind  is  usually  serene  and  cheerful, 
but  periods  of  depression  are  not  infrequent.  The  sensibilities 
are  blunted  and  the  animal  nature  emphasized.  The  mind 
becomes  more  and  more  involved  ;  there  is  extreme  indifference 
to  all  that  transpires ;  the  appetite  is  voracious,  and  in  eating 
the  patient  bolts  his  food  and  soils  his  clothes.  The  tremor 
of  the  tongue  increases,  and  spreads  to  the  lips  and  other  parts 
of  the  face;  the  speech  is  indistinct  and  "scanning;"  the  pupils 
fail  to  respond  to  light,  but  still  accommodate  for  distance 
(Argyll-Robertson  pupil) ;  the  reflexes  are  generally  increased. 
Spellsofunconsciousnessresemblingj5di^?na^  are  not  uncommon. 

In  the  final  stage  mental  power  is  almost  obliterated  ;  the 
health  fails ;  the  bladder  and  rectum  become  unretentive  ;  the 
gait  is  more  unsteady ;  and  at  last  the  patient  is  unable  to 
leave  his  bed.  Death  usually  results  from  exhaustion  or  in- 
tercurrent disease. 

Diagnosis. — The  insidious  change  in  disposition,  failure  of 
memory,  tremors,  Argyll-Robertson  pupil,  and  delusions  of 
grandeur  are  the  diagnostic  features. 

Cerebral  Syphilis. — In  this  disease  the  history,  the  occur- 
rence of  convulsions  and  of  partial  facial  palsies,  the  absence 
of  delusions  of  grandeur  and  of  "  scanning"  speech,  and  the 
effect  of  treatment  will  usually  prevent  an  error  in  diagnosis. 

Prognosis. — Unfavorable.  The  course  is  not  uniform  ;  in 
some  cases  there  are  remissions,  or  lucid  intervals,  which  last 
several  months  or  years.  The  average  duration  is  three  or 
four  years. 

Treatment. — Rest  of  body  and  mind.     Careful  attention 

22 


338  DISEASES   OF  THE  NERVOUS  SYSTEM. 

to  the  hygiene.  When  there  is  a  suspicion  of  syphilis,  iodides 
and  mercurials  should  be  given  a  thorough  trial.  As  a  rule, 
patients  must  be  removed  to  asylums. 

CEREBKAL  PARALYSIS  IN  CHILDREN. 

Definition.  —  Hemiplegia^  diplegia,  or  paraplegia  ap- 
pearing at  birth  or  in  the  first  few  years  of  life,  and  usually 
associated  with  atrophy  and  sclerosis  of  the  cerebral  cortex, 
or  porencephalus. 

Pathology. — After  death  one  of  the  following  conditions 
is  observed  :  Atrophy  and  sclerosis  of  the  convolutions ;  poren- 
cephalus  (a  cystic  condition  of  the  cortex) ;  or  more  rarely, 
some  local  obstruction  to  the  cerebral  circulation,  as  from 
hemorrhage,  embolism,  or  thrombosis.  The  exciting  cause  of 
the  porencephalus^aucl  sclerosis  is  still  undetermined. 

Symptoms. — In  the  hemiplegic  variety  the  onset  is  sudden, 
and  is  frequently  attended  with  fever,  convulsions^or  coma. 
After  a  few  hours  or  davs  these  severe  symptoms  si5bsi3e,  and 
the  child  is  left  paralyzed  on  one  side  of  the  body.  In  rare 
instances  the  paralysis  ultimately  disappears  and  the  child  is 
restored  to  health,  but  in  the  large  majority  of  cases  it  persists 
land  is  followed  by  secondary  rigidity.  Imbecility,__epilepsy, 
and  choreiforDi  or  athetoid  movements  in  the  affected  members 
are  very  common  sequelae. 

The  diplegic  or  paraplegic  form  frequently  dates  from  birth, 
and  is  characterized  by  rigidity  and  loss  of  power  in  all  of  the 
extremities.  The  legs  suffer  more  than  the  arms.  Chorei- 
form or  athetoid  movements  are  frequently  present.  Children 
thus  affected  are  generally  idiots  or  imbeciles.  Meningeal 
j  hemorrhage,  induced  by  tedious  labor  or  the  use  of  the  for- 
(  ceps,  appears  to  be  responsible  for  this  variety. 

Treatment. — During  the  convulsive  stage  an  ice-bag 
should  be  applied  to  the  head,  and  chloral  or  bromide  admin- 
istered by  the  mouth  or  rectum.  The  paralysis  resists  treat- 
ment ;  but  subsequent  rigidity  may  be  lessened  by  massage 
and  passive  movements,  and  the  deformity  by  mechanical 
appliances.^ 

•  The  above  description  is  based  upon  Osier's  elaborate  monograph. 


CEREBRAL   HYPERiEMlA.  339 

CEREBRAL  HYPEREMIA. 

(Congestion  of  the  Brain.) 

Etiology. — Acute  congestion  results  from  exposure  to  the 
sun ;  from  the  use  of  certain  drugs,  like  alcohol  and  nitro- 
glycerine ;  from  excesssive  brain-work ;  or  from  some  reflex 
disturbance,  as  gastric  irritation. 

Chronic^congestion  results  from  some  local  obstruction  to 
the  return  oFolood  from  the  brain,  as  by  a  tumorja^the  neck ; 
from  obstruction  to  the  general  circulation,  as  in  chronic^heart 
and  lung  disease ;  from  the  suppression  of  some  habitual  dis- 
charge, as  the  menstrual  flow  at  the  menopause  ;  or  from  some 
general  cause,  such  as  prolonged  anxiety,  overwork,  excesses, 
irregular  living,  etc. 

Pathology. — The  vessels   of  the   meninges  and  of  the  / 
brain-substance  are  engorged. 

Symptoms.  Acute  Form. — Intense  headache;  vertigo; 
intolerance  to  light  and  sound  ;  restlessness  ;  tinnitus  aurium ; 
and  sleeplessness,  or  sleep  disturbed  by  horrible  dreams. 

Chronic     Form.  —  Vertigo  ;    dull     headache ;     failure    of  / 
memory  ;   irritability ;  inability  to  concentrate  the  thoughts ;  / 
and  disturbed  sleep.    The  symptoms  grow  worse  when  the  re-^ 
cumbent  posture  is  assumed.     Ophthalmoscopic  examination 
reveals  retinal  hyperemia.     In  marked  cases  there  may  be 
exacerbations  closely  resembling  apoplexy,  in  which  there  is 
unconsciousness,  followed  by  temporary  paresis. 

Prognosis. — Depends  on  the  cause;  when  this  can  be 
removed  the  prognosis  is  favorable. 

Treatment.  Acute  Congestion. — The  patient  should  be 
placed  in  a  darkened,  well-ventilated  room.  The  head  and 
shoulders  should  be  slightly  elevated.  An  ice-bag  should  be 
applied  to  the  head.  Leeches  or  wet-cups  may  be  applied  to 
the  neck.  Sedatives  like  bromide  of  potassium  and  aconite 
are  useful.  Ergot  may  be  employed  for  its  power  to  contract 
the  vessels.  If  there  is  constipation,  it  should  be  relieved  by  a 
brisk  saline  purge. 

In  chronic  cases  the  cause  should  be  ascertained  and,  if 
possible,  removed.     The  habits  of  the  patient  must  be  regu- 


340  DISEASES  OF  THE  NERVOUS  SYSTEM, 

lated.  The  diet  must  be  light  and  nutritious.  Constipation 
must  be  relieved  by  diet  or  by  the  occasional  use  of  a  saline 
laxative.  Sedatives  like  bromide  of  potassium  and  aconite  are 
useful.     In  the  apoplectiform  attacks  venesection  is  indicated. 

CEREBRAL  A^^^MIA. 

Etiology. — General  cerebral  anaemia  as  a  chronic  affection 
may  result  from  cardiac  disease,  especially  aortic  stenosis.  It 
may  l)e  associated  with  general  anaemia.  It  may  be  due  to 
atheromatous  obstruction  of  the  arteries. 

Overwork,  prolonged  emotional  excitement,  irregular  living, 
and  excesses  are  also  said  to  predispose. 

As  an  acute  condition  it  exists  in  syncope  and  shock  ;  after 
hemorrhage ;  after  the  sudden  withdrawal  of  fluid  from  the 
abdominal  sac ;  and  after  ligation  of  the  carotid  artery. 

Symptoms.  Acute  Form. — Pallor  of  the  face,  vertigo, 
confusion  of  ideas,  ringing  in  the  ears,  dimness  of  vision,  dila- 
tation of  the  pupil,  nausea,  and  a  tendency  to  yawn.  In 
extreme  anaemia  there  may  be  convulsions  and  coma. 

I  The  chronic  form  is  characterized  by  vertigo,  headache,  dis- 
turbed 'sleep,  intolerance  to  light  and  sound,  irritability  of 
temper,  failure  of  memory,  inability  to  concentrate  the  atten- 
j  tion  on  one  subject,  a  tendency  to  syncope,  and  extreme  lassi- 
tude. The  symptoms  improve  when  the  patient  lies  down. 
Ophthalmoscopic  examination  reveals  pallor  of  the  retina. 

Diagnosis. — Cerebral  anaemia  closely  simulates  cerebral 
congestion,  but  in  the  latter  there  is  no  tendency  to  syncope ; 
the  symptoms  grow  worse  when  the  patient  lies  down ;  and  the 
ophthalmoscope  reveals  retinal  hyperaemia. 

Prognosis. — Depends  on  the  cause ;  when  this  can  be  re- 
moved the  prognosis  is  favorable. 

Treatment. — In  acute  cases  diffusible  stimulants  like 
nitro-glycerin,  ammonia,  and  strychnia  are  indicated.  In 
chronic  cases  the  cause  should  be  ascertained,  and  if  possible, 
removed.  When  it  is  due  to  general  anaemia,  iron,  arsenic, 
and  quinine  are  useful  remedies.  When  dependent  on  valvu- 
lar disease,  rest  and  the  use  of  digitalis,  strophanthus,  or 
strychnine  are  the  remedial  measures. 


CEEEBRAL,   HEMORRHAGE.  341 

CEREBRAL  HEMORRHAGE. 

(Cerebral  Apoplexy.) 

Etiology. — The  affection  is  most  commonly  met  with  in 
the  old,  in  whom  the  bloodvessels  are  atheromatous,  and  in 
the  very  young,  in  whom  they  are  naturally  weak.  All 
causes  which  lead  to  degeneration  of  the  arteries,  such  as 
rheumatism,  gout,  syphilis,  alcoholism,  and  Bright's  disease, 
predispose  to  it.  Sufferers  from  chronic  Bright's  disease  are 
very  liable  to  die  of  apoplexy  on  account  of  the  association  of 
cardiac  hypertrophy  with  arterial  degeneration.  Heredity 
predisposes,  inasmuch  as  members  of  certain  families  are 
particularly  prone  to  sclerosis  of  the  vessels.  The  attack 
may  be  precipitated  by  mental  or  physical  excitement,  alco- 
holic excess,  or  some  reflex  disturbance,  as  gastric  irritation. 
In  children  it  may  be  excited  by  a  paroxysm  of  whooping- 
cough  or  by  a  convulsion. 

Pathology. — In  children  the  hemorrhage  is  most  com- 
monly cortical ;  in  adults  it  is  usually  within  the  brain-mass. 
The  bloodvessels  are  generally  atheromatous,  and  are  some- 
times the  seat  of  miliary  aneurisms.  The  clot  varies  greatly 
in  size ;  sometimes  it  is  small,  merely  a  capillary  oozing ;  at 
other  times  it  may  fill  a  hemisphere.  Its  most  common  seat 
is  the  internal  capsule — the  motor  highway  between  the  optic 
thalamus  and  the  corpus  striatum.  In  recent  hemorrhages 
the  clot  is  dark  and  soft,  and  the  surrounding  tissue  stained 
and  more  or  less  lacerated.  If  .the  hemon-hage  has  not  been 
very  copious,  the  clot  loses  it  color,  shrinks,  and  is  finally 
absorbed,  and  the  damaged  cerebral  fibres  are  replaced  by 
proliferated  connective  tissue,  which  contracts  and  forms  a 
scar  more  or  less  pigmented  with  hsematoidin^  In  other  cases, 
instead  of  a  scar,  a  cyst  is  formed  which  encloses  a  clear  straw- 
colored  fluid.  Large  effusions  in  the  motor  path  may  produce 
secondary  changes — either  a  softening  of  the  cerebral  tissue 
beyond,  or  a  degeneration  which  travels  down  the  lateral 
column  of  the  cord  on  the  side  opposite  the  lesion. 

Symptoms. — Prodromal  symptoms  indicating  cerebral  con- 
gestion frequently  precede  the  attack ;   these  are  headache, 


342  DISEASES   OF   THE  NERVOUS  SYSTEM. 

vertigo,  disturbed  sleep,  tinnitus  auriura ;  or  there  is  a  sense 
of  numbness  or  weakness  on  the  side  which  is  to  be  affected. 
Persistent  vomiting  sometimes  precedes  the  hemorrhage. 

The  Attack. — In  many  cases  the  patient  falls  suddenly  un- 
conscious without  previous  warning.  The  face  is  flushed ; 
the  eyes  are  injected;  the  lips  are  blue;  the  breathing  is  ster- 
torous ;  the  pulse  is  full  and  slow ;  the  temperature  is  at  first 
subnormal  from  shock,  but  later  it  is  elevated  from  irritation ; 
and  the  urine  and  feces  may  be  passed  involuntarily.  Convul- 
sive seizures  are  not  infrequent;  they  result  from  irritation 
transmitted  to  the  undamaged  motor  regions.  Even  while  the 
patient  is  comatose  the  paralysis  can  be  detected.  The  head 
and  eyes  may  be  strongly  rotated  to  one  side  (conjugate  devia- 
tion) ;  one  cheek  often  flaps  more  than  the  other ;  the  pupils 
may  be  irregular ;  any  movements  which  the  patient  may 
make  are  restricted  to  the  sound. side;  when  the  affected  arm 
is  raised  and  let  fall,  it  drops  lifeless  or  manifests  an  unnatural 
rigidity ;  and  occasionally  there  is  a  difference  of  temperature 
in  the  two  axillae.  In  grave  cases  the  patient  does  not  awake 
from  the  coma ;  the  pulse  grows  feeble ;  the  respirations  assume 
the  Cheyne-Stokes  type ;  the  reflexes  are  abolished ;  mucus  col- 
lects in  the  throat  and  produces  a  rattling  sound  ;  the  tempera- 
ture rises  high  ;  and  death  results  after  the  lapse  of  a  few  hours 
or  one  or  two  days. 

In  some  cases  the  paralysis  develops  quite  gradually  and  is 
not  attended  with  unconsciousness. 

Subsequent  Symptoms.  —  When  the  attack  does  not  prove 
fatal,  consciousness  is  finally*i'estored,  and  if  the  hemorrhage 
is  in  its  usual  location,  there  remains  a  hemiplegia  on  the 
opposite  side.  In  a  few  hours  the  affected  muscles  become 
rigid  from  irritation  of  the  motor  fibi'es.  This  early  rigidity 
is  termed  primary  rigidity ;  it  lasts  from  a  few  days  to  several 
weeks  and  has  no  significance  from  a  prognostic  standpoint.  The 
paralysis  is  rarely  a  complete  hemiplegia  ;  the  muscles  of  the 
upper  part  of  the  face  and  thorax  usually  escape,  because  they 
are  accustomed  to  act  in  unison  with  their  fellows  on  the  op- 
posite side,  and  such  muscles  are  rarely  involved  in  cerebral 
hemiplegia.  When  the  tongue  is  protruded,  it  deviates  toward 
the  paralyzed  side.      The  deep  reflexes  are  exaggerated   on 


CEREBRAL,   HEMORRHAGE.  343 

the  affected  side.  Sensation  is  unimpaired  unless  the  pos- 
terior limb  of  the  internal  capsule  is  also  involved,  when  there 
is  hemiansesthesia  with  hemiplegia.  The  gait  is  peculiar ;  in 
walking  the  patient  supports  the  paralyzed  arm,  and  swings 
the  leg  forward  by  a  rotary  movement  imparted  to  it  by  the 
trunk.  When  the  clot  has  been  small,  the  paralysis  may 
completely  disappear.  More  frequently  recovery  is  only  par- 
tial ;  the  power  of  the  facial  muscles  is  usually  restored 
entirely,  and  the  leg  improves  more  than  the  arm.  In  unfavor- 
able cases  the  muscles  again  become  rigid  (secondary  rigidity) 
from  a  degenerative  process  travelling  down  the  lateral  column 
of  the  cord ;  this  condition  is  indicative  of  permanent  dis- 
ability. Generally  the  mental  power  remains  unimpaired, 
but  sometimes  the  symptoms  of  cerebral  softening  gradually 
develop. 

Diagnosis. — The  coma  of  apoplexy  must  be  distinguished 
from  uraemia,  opium-poisoning,  alcoholism,  and  sunsti'oke.  The 
age  of  the  patient ;  the  condition  of  the  arteries  ;  the  evidence 
of  paralysis  ;  the  difference  of  temperature  in  the  two  axillae ; 
and  the  absence  of  other  cause  will  usually  prevent  an  error  in 
diagnosis. 

Embolism. — This  usually  occurs  in  earlier  life ;  it  is  com- 
monly associated  with  valvular  disease;  the  paralysis  is  almost 
invariably  on  the  right  side;  aphasia  is  more  common;  there 
is  less  disturbance  of  temperature  ;  and  consciousness  may  not 
be  lost. 

Thrombosis.  —  This  also  produces  hemiplegia,  but  its  de- 
velopment is  very  gradual. 

Hemiplegia  from  other  Causes. — Tumors  and  abscess  in  the 
br'ain  may  produce  hemiplegia,  but  the  latter  develops  gradu- 
ally and  is  usually  associated  with  other  cerebral  phenomena, 
such  as  persistent  headache,  vertigo,  ocular  palsies,  choked 
disk,  etc. 

Hysterical  Hemiplegia. — In  hysteria  the  face  escapes  ;  there 
is  frequently  anaesthesia  on  the  affected  side  ;  the  gait  is  pecu- 
liar, in  that  the  patient  pushes  the  paralyzed  limb  instead  of 
swinging  it.  These  features  together  with  the  age,  tempera- 
ment, sex,  and  mode  of  onset  will  usually  suggest  the  true 
cause. 


344  DISEASES  OF  THE  NEHVOUS  SYSTEM. 

Prognosis, — Always  doubtful.  Persistent  and  complete 
unconsciousness,  high  temperature,  loss  of  reflexes,  and  embar- 
rassed respiration  are  unfavorable  phenomena.  When  the  at- 
tack does  not  prove  fatal,  there  is  always  a  probability  of 
subsequent  ones,  for  the  etiological  conditions  still  remain. 

Treatment.  Prophylaxis. — Patients  predisposed  to  apo- 
plexy should  lead  a  quiet  life,  free  from  mental  and  physical 
excitement.  The  diet  should  be  nutritious,  but  easily  diges- 
tible. Constipation  should  be  relieved  by  the  occasional  use  of 
a  saline  laxative.  To  secure  a  free  return  of  the  blood  from 
the  brain  the  clothes  at  the  neck  should  be  loose. 

The  Attack. — The  head  and  shoulders  should  be  slightly 
elevated,  and  an  ice-bag  applied  to  the  head.  Croton  oil 
(gtt.  j— iij)  in  a  little  glycerine  or  olive  oil  may  be  placed  on 
the  back  of  the  tongue  to  secure  prompt  catharsis.  If  the 
pulse  is  strong,  venesection  is  indicated  and  should  be  con- 
tinued until  the  pulse  softens.  Bleeding  cannot  undo  the 
damage  already  done,  but  by  relieving  cerebral  congestion  it 
may  prevent  a  renewed  outpouring.  On  the  other  hand,  when 
the  face  is  pale  and  the  pulse  feeble  the  hypodermic  injection 
of  diifusible  stimulants,  like  ammonia  and  strychnia,  is  indi- 
cated. When  collections  of  mucus  interfere  with  breathing,  the 
patient  should  be  gently  turned  on  his  side  and  the  mucus 
removed. 

To  prevent  the  formation  of  bedsores  the  position  should 
be  frequently  changed,  and  the  parts  subjected  to  pressure 
thoroughly  cleansed. 

Subsequent  Treatment. — As  other  attacks  are  liable  to  occur, 
the  prophylactic  treatment  already  referred  to  is  applicable 
here.  Iodide  of  potassium  (gr.  v-x  thrice  daily)  may  be  ad- 
ministered with  the  hope  of  absorbing  the  clot.  After  the 
primary  rigidity  has  disappeared,  galvanism,  massage,  and 
passive  movements  should  be  applied  to  the  affected  muscles. 
StTychuine  by  the  mouth  or  injected  directly  into  the  muscles  is 
often  very  useful.  Even  when  the  paralysis  remains,  con- 
tractures may  be  prevented  to  a  considerable  extent  by 
massage. 


OBSTRUCTION  OF  THE  CEREBRAL  ARTERIES.  345 

OBSTRUCTION  OF  THE  CEREBRAL.  ABTERIES. 

(Embolism,  Thrombosis.) 

Etiology. —  Cerebral  emboli  may  be  derived  from  the 
valves  of  the  heart  in  endocarditis  ;  from  an  atheromatous  plate 
in  the  aorta ;  or  irom  a  clot  in  the  heart  or  in  the  sac  of  an 
aneurism.  Obstruction  from  embolism  may  occur  at  any 
age,  but  it  is  far  more  commonly  observed  in  young  adults 
than  at  the  extremes  of  life. 

Thrombi  are  clots  formed  in  the  vessels,  and  a  weak  heart 
and  arterial  degeneration  are  the  predisposing  factors.  They 
are  usually  observed  in  advanced  years,  but  those  dependent 
on  syphilitic  arteritis  frequently  occur  in  early  adult  or  middle 
life. 

Pathology. — Emboli  are  most  frequently  found  in  ai 
branch  of  the  left  middle  cerebral  artery.  When  the  artery  ^ 
obstructed  is  a  large  one,  the  part  beyond  usually  becomes 
pale  and  soft;  but  sometimes  it  presents  the  appearance  of 
an  infarction  and  is  infiltrated  with  blood.  Subsequently, 
microscopic  examination  reveals  fatty  degeneration  of  the 
nervous  elements  and  more  or  less  pigmentation  from  extra- 
vasated  blood.  If  the  area  affected  is  small,  absorption  may 
follow  and  scar-tissue  be  substituted. 

Thrombi  are  usually  found  in  the  middle  cerebral,  basilar,  I 
or  vertebral  arteries,  and  are  followed  by  similar  changes. 

Symptoms. — An  embolus  lodging  in  the  middle  cerebral 
artery   usually    causes  abrupt    hemiplegia,    and    frequently  \ 
aphasia.     There  may  be  no  prodromes,  and  consciousness  is  I 
often  preserved  during  the  seizure. 

When  the  basilar  artery  is  obstructed,  there  may  be  exten- , 
sive  paralysis  on  both  sides  of  the  body,  and  later,  symptoms  1 
of  bulbar  disease,  namely,  paralysis  of  the  lips,  pharynx,! 
and  oesophagus,  disturbance  of  tlie  heart,  and  Cheyne-Stoke^/ 
breathing.  j 

/n  thrombosis  the  symptoms  are  similar  to  embolism,  but  they 
develop  very  slowly,  and  are  frequently  preceded  by  prodrom^ 
indicating  disturbed  cerebral    circulation,  such   as  headache,  \ 
vertigo,    disturbed   sleep,  failure  of  memory,  numbness  and  \    / 
tingling  in  the  limbs  to  be  affected.  V 


f 


346  DISEASES  OF  THE   NERVOUS   SYSTEM. 

Subsequent  Symptoms. — In  both  embolism  and  thrombosis, 
if  the  artery  obstructed  has  been  large,  the  paralysis  persists 
and  symptoms  of  cerebral  softening  appear — namely,  failure 
of  memory,  vertigo,  headache,  disturbed  sleep,  great  irrita- 
bility, and  finally  dementia. 

Diagnosis. — Cerebral  embolism  closely  resembles  apoplexy, 
and  sometimes  it  may  be  impossible  to  distinguish  between  the 
two  conditions.     The  following  are  the  diagnostic  features  : — 

Embolism  is  generally  associated  with  valvular  disease  ;  it 
commonly  occurs  in  the  young ;  prodromes  are  frequently  ab- 
sent ;  the  left  middle  cerebral  artery  being  almost  invariably 
.  involved,  the  hemiplegia  is  on  the  right  side ;  aphasia  is  more 
\  common  in  embolism  than  in  hemorrhage ;  there  is  much  less 
j  disturbance  of  temperature  after  embolism  than  after  apo- 
plexy ;  consciousness  is  less  apt  to  be  lost  in  embolism  than  in 
apoplexy. 

Peognosis. — In  embolism  it  is  very  doubtful ;  recovery 
may  follow,  but  often  the  paralysis  remains.  In  thrombosis 
there  is  very  little  hope  of  recovery,  unless  the  cause  is  syphilis. 

Treatment. — After  obstruction  from  embolism  the  patient 
should  be  kept  at  absolute  rest  for  a  few  days,  and  subsequently 
the  paralysis  treated  as  after  apoplexy.  In  thrombosis  treat- 
ment is  of  no  avail,  save  in  syphilitic  subjects,  when  mercurial 
inunctions  should  be  employed  freely  and  the  bichloride  given 
by  the  mouth. 

CEREBRAL  SOFTENING. 

Definition. — Degeneration  of  the  brain-substance  resulting 
Lfrom  perverted  nutrition. 

Etiology. — Local  softening  may  result  from  obstruction 
to  the  circulation  by  a  tumor,  embolism,  thrombosis,  or  clot. 
Extensive  softening  may  result  from  prolonged  cerebral  anaemia 
or  congestion.  It  is  most  frequently  observed  in  old  people  in 
association  with  atheromatous  arteries. 

Pathology. — The  aFected  portion  is  dull  white  or  reddish- 
yellow,  according  to  the  amount  of  blood-pigment  present; 
and  is  less  firm  than  the  surrounding  brain-substance.  Some- 
times it  is  so  soft  that  when  the  brain  is  cut  a  creamy  fluid 


MORBID'  GROWTHS   IN  THE   BRAIIST.  347 

flows  out.  Microscopic  examination  reveals  destruction  of  the 
nerve-elements  and  their  substitution  by  granular  debris  and 
fat-drops. 

Symptoms. — When  extensive  the  symptoms  are :  Failure  i 
of  memory,  irritability  of  temper,  vertigo,  headache,  partial  ' 
palsies,  cutaneous  anaesthesia  or  parsesthesia,  delusions,  and  *' 
finally  dementia. 

Local  softening  may  be  manifested  by  local  paralysis. 

Diagnosis.  Cerebral  Tumor. — Tumors  usually  develop  in 
younger  subjects  ;  the  headache  is  more  severe ;  choked  disk 
is  frequently  observed. 

Prognosis. — Unfavorable. 

Treatment. — Palliative. 

MOKBID  GROWTHS  IN  THE  BRAIN. 

^(Tumors  of  the  Brain.) 

Etiology. — Early  adult  life,  male  sex,  and  perhaps  trau- 
matism predispose.  Heredity  also  predisposes  to  the  extent 
that  it  favors  the  development  of  cancer,  gumma,  and  tubercle. 

Varieties.  —  Tubercle,  gumma,  glioma,  cysts,  sarcoma, 
and  carcinoma  are  the  most  common  varieties.  Less  frequently 
fibroma,  psammoma,  and  lipoma  are  observed. 

Pathology. — Tuberculous  tumors,  or  tyi^omata,  vary  in  size 
from  a  pea  to  an  egg ;  they  may  be  single  or  multiple ;  and 
are  usually  observed  in  the  young. 

Gumma. — This  appears  as  a  round,  yellow,  caseous  mass, 
and  is  nearly  always  on  the  surface  of  the  brain,  into  which  it 
grows  from  the  overlying  membranes.  It  is  usually  met  with 
between  thirty  and  forty. 

Glioma. — This  tumor  is  found  almost  exclusively  in  the 
brain.  It  arises  from  the  neuroglia,  and  may  be  soft  like 
brain-substance  or  firm  like  fibrous  tissue.  It  is  chiefly  met 
with  in  the  young. 

Cysts. — These  are  usually  congenital  (porencephalus),  but 
sometimes  they  result  from  the  taenia  echinococcus  (hydatid 
cyst). 

Sarcoma. — This  is  usually  a  diffuse  tumor,  and  grows  from 
the  membranes. 


348  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Carcinoma. — This  is  nearly  always  secondary  and  multiple. 

Symptoms. — (1)  Headache  is  rarely  absent;  it  may  be 
localized  and  associated  with  tenderness  on  pressure,  (2) 
Vomiting  is  a  common  symptom,  especially  in  tumors  of  the 
base  of  the  brain ;  it  is  often  unassociated  with  nausea  and 
does  not  relieve  the  attending  headache,  (3)  Ocular  phe- 
nomena, as  optic  neuritis,  or  choked  disk,  optic  atrophy,  diplo- 
pia, hemianopia,  blindness,  and  irregular  pupils.  (4)  Vertigo, 
(5)  Psychical  phenomena,  as  failure  of  memory,  irritability 
of  temper,  depression  of  spirits,  and  dementia.  (6)  Symp- 
toms resulting  from  local  pressure,  such  as  local  palsies  or 
convulsions,  aphasia,  and  local  anaesthesia. 

Diagnosis. — This  includes  :  (1)  the  existence  of  a  tumor, 
(2)  its  character,  and  (3)  its  location. 

The  existence  of  a  tumor  is  determined  by  the  headache, 
vomiting,  optic  neuritis,  and  symptoms  of  local  jjressnre. 

Abscess.  —  Cerebral  tumor  must  be  distinguished  from 
abscess.  The  latter  usually  results  from  traumatism  or  is 
secondary  to  a  focus  of  suppuration  in  some  other  part  of  the 
body ;  its  progress  is  more  rapid ;  choked  disk  is  rare ;  and 
there  is  often  febrile  disturbance. 

Chronic  Meningitis. — In  this  affection  the  symptoms  indi- 
cate a  diffuse  lesion;  disturbances  of  temper,  memory,  and  sleep 
are  more  marked ;  and  optic  neuritis  is  rarely  observed. 

The  Character  of  the  Gh^owth. — This  cannot  always  be  deter- 
mined. The  early  age,  the  rapid  progress,  and  the  family 
history  may  suggest  tubercle.  The  early  age,  slow  progress, 
and  mild  pressure-symptoms  may  suggest  glioma.  The  his- 
tory, age,  and  concomitant  symptoms  will  indicate  'syphilis. 
The  presence  of  a  primary  growth  will  lead  to  the  diagnosis 
of  cancer. 

Location. — The  following  facts  relating  to  cerebral  localiza- 
tion will  aid  in  determining  the  location  of  the  growth. 

Motor  area.  This  consists  of  the  ascending  frontal  and 
ascending  parietal  convolutions,  and  the  paracentral  lobule 
which  lies  along  the  median  fissure.  When  the  tumor  irritates 
the  part,  convulsion  results ;  when  it  exerts  enough  pressure 
to  destroy  function,  paralysis  results. 


MORBID   GROWTHS   IN  THE   BRAIN.  349 

Paraeentral  lobule — spasm  or  paralysis  of  a  lower  ex- 
tremity. 

Centi'al  portion  of  the  motor  area — spasm  or  paralysis  of  one 
arm. 

The  loiver  portion  of  the  motor  area — spasm  or  paralysis  of 
one  side  of  the  face. 

Posterior  part  of  the  third  frontal  convolution  (left  Bide) — 
motor  or  ataxic  aphasia. 

Anterior  portion  of  the  frontal  lobes — sometimes  psychical 
disturbances;  often  no  special  symptoms. 

Temporal  lobe,  first  and  second  convolutions  {left  side) — word- 
deafness. 

Parietal  lobe — sensory  disturbances  on  opposite  side  of  body. 

Angular  and  supramarginal  gyri  (left  side) — word-blindness 
and  mind-blindness.   . 

Occipital  lobe — hemianopsia,  and  .sometimes  word-blindness 
and  mind-blindness. 

Corpus  striatum — large  lesions  produce  hemiplegia  from 
pressure  on  the  internal  capsule. 

Optic  thalamus — large  lesions  may  produce  hemiansesthesia 
from  pressure  upon  the  posterior  limb  of  the  internal  capsule, 
and  sometimes  hemianopsia. 

Corpora  quadrigemina — hemianopsia,  nystagmus,  and  symp- 
toms resulting  from  pressure  on  the  crura  cerebri. 

Crus  cerebri — hemiplegia  on  one  side,  and  paralysis  of  the 
oculo-motor  nerve  on  the  other. 

Pons — paralysis  of  tiie  cranial  nerves,  and  in  many  cases 
hemiplegia  and  hemiansesthesia  on  one  side,  and  facial  paralysis 
on  the  other.     Bilateral  lesions  may  produce  general  paralysis. 

Internal  capsule  (middle  third) — hemiplegia  on  the  opposite 
side.     Posterior  third — hemianesthesia  on  the  opposite  side. 

Medulla — paralysis  of  the  cranial  nerves,  difficult  articu- 
lation, cardiac  and  respiratory  disturbances,  vomiting,  and 
sometimes  hemiplegia. 

Cerebellum  (middle  lobe)  —  staggering  gait,  vomiting, 
vertigo,  and  marked  headache. 

Prognosis. — When  the  tumor  is  not  gummatous,  and  is 
not  suitable  for  operative  interference,  the  prognosis  is  unfavor- 
able.    The  duration  is  from  a  few  months  to  several  years. 


350  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Treatment. — Localized  cortical  growths,  which  are  not 
malignant  or  syphilitic,  are  suitable  for  operative  interference. 
In  cerebral  gumma  inunctions  of  mercury  should  be  employed, 
and  mercury  and  iodide  of  potassium  given  by  the  mouth.  In 
other  cases  the  treatment  is  palliative.  Cold  applications  to 
the  head,  bromides,  antipyrin,  and  morphine  are  required  to 
relieve  pain. 

ABSCESS  OF  THE  BRAIN. 

{ Suppurative  Encephalitis . ) 

Etiology. — (1)  It  may  be  traumatic.  (2)  It  may  be  se- 
condary to  suppurative  inflammation  of  adjacent  parts,  as 
caries  of  the  temporal  bone  following  otitis  media.  (3)  It 
may  be  secondary  to  some  distant  focus  of  suppuration,  as  in 
pulmonary  abscess,  hepatic  abscess,  ulcerative  endocarditis. 
(4)  It  may  follow  one  of  the  infectious  fevers. 

Pathology. — The  abscess  varies  in  size  from  a  pea  to  one 
large  enough  to  fill  an  entire  hemisphere.  The  surrounding 
tissues  are  hypersemic,  cedematous,  and  more  or  less  infiltrated. 
In  the  acute  form  the  abscess  is  diffuse,  but  in  long-standing 
cases  the  pus  is  encapsulated  by  a  thick  fibrous  sac.  The 
temporo-sphenoidal  lobe  and  the  cerebellum  are  the  most 
frequent  seats.  Abscesses  secondary  to  distant  foci  of  sup- 
puration are  commonly  multiple. 

Symptoms. — Abscesses  following  injury  frequently  run  an 
acute  course,  and  are  characterized  by  high  fever,  rigors,  head- 
ache, delirium,  convulsions,  vomiting,  and  coma. 

In  chronic  cases  the  general  symptoms  are  headache,  irrita- 
bility, mental  impairment,  vertigo,  vomiting,  irregular  fever, 
stupor,  pallor,  and  loss  of  flesh  and  strength.  The  focal 
phenomena  vary  with  the  location  of  the  abscess.  Involve- 
ment of  the  motor  area  may  be  attended  with  convulsions  or 
paralysis  in  one  limb ;  of  the  temporo-sphenoidal  lobe,  with 
deafness,  and  perhaps  aphasia ;  of  the  occipital  lobe,  with 
hemianopia ;  of  the  cerebellum,  with  persistent  vomiting  and 
loss  of  coordination. 

Diagnosis.  Cerebral  Tumors. — The  history  of  traumatism 
or  of  some  primary  suppurating  disease,  such  as  otitis,  bron- 


CKETIJSriSM.  351 

chiectasis,  empyema,  ulcerative  endocarditis ;  the  presence  of 
fever,  and  the  absence  of  choked  disk  will  indicate  abscess. 

Acute  cases  can  rarely  be  distinguished  from  suppurative 
meningitis. 

Peognosis. — Grave.  When  tKe  focal  symptoms  indicate 
involvement  of  an  accessible  region  like  the  motor  area, 
temporo-sphenoidal  lobe,  or  cerebellum,  operative  interference 
aflfbrds  considerable  hope  of  success. 

Treatment. — When  the  abscess  is  located  in  one  of  the 
regions  specified,  the  skull  should  be  trephined  and  the  pus 
evacuated.  In  other  cases  the  application  of  wet  cups  to  the 
neck,  of  ice-bags  to  the  head,  and  the  internal  use  of  opium, 
bromide  of  potassium,  or  of  chloral,  may  temporarily  relieve 
the  distress. 

CRETmiSM. 

Definition. — A  congenital  affection,  characterized  by  a 
lack  of  physical  development,  an  abnormal  condition  of  the 
thyroid  gland,  myxoedema,  and  idiocy  or  imbecility. 

Etiology. — Beyond  heredity  no  cause  is  known.  The 
condition  is  endemic  in  the  Alps  and  Pyrenees.  Sporadic 
cases  are  also  observed  in  other  parts  of  the  world. 

Symptoms.  Endemic  Cretinism.  —  The  stature  is  short 
(three  or  four  feet) ;  the  head  is  large,  flat  antero-posteriorly 
and  broad  laterally  ;  the  eyes  are  wide  apart ;  the  nose  is  flat; 
the  lips  are  thick ;  the  tongue  is  large  and  may  protrude  from 
the  mouth ;  the  chest  is  narrow  ;  the  belly  is  prominent ;  the 
fingers  are  short;  the  genitalia  are  not  developed  ;  the  sub- 
cutaneous tissues,  especially  at  the  root  of  the  neck,  are 
thickened  from  mucoid  or  fatty  deposits ;  the  thyroid  gland  is 
frequently  enlarged ;  and  the  mental  condition  is  that  of  idiocy. 

Sporadic  cases  present  the  same  features,  but  the  thyroid, 
instead  of  being  larger,  is  often  atrophied. 

Congenital  conditions  presenting  to  a  limited  extent   the  , 
phenomena  of  cretinism,  are  termed  cretinoid. 

Treatment. — Encouraging  results  have  followed  the  use 
of  an  extract  of  the  thyroid  gland. 


352  DISEASES   OF  THE   NEEVOUS   SYSTEM. 

SPEN^AL.  LEPTOMENEVGITIS. 

(Spinal  Meningitis.) 

Definition. — An  inflammation  of  the  spinal  pia  mater  not 
associated  with  infectious  cerebro-spinal  meningitis. 

Etiology, — The  infectious  fevers,  exposure  to  cold  and  wet, 
traumatism,  and  tuberculosis  are  the  etiological  factors. 

Pathology.  Acute  Form. — The  membranes  are  opaque, 
thickened,  congested,  and  adherent.  The  fluid  in  the  arach- 
noid space  is  increased.  In  very  acute  cases  there  is  more  or 
less  purulent  infiltration.  The  periphery  of  the  cord  is  al- 
ways involved. 

Chronic  Form. — The  membranes  are  very  thick  and  fused 
iuto  one  homogeneous  fibrous  mass. 

Symptoms.  Acute  Form. — The  disease  may  begin  with  a 
chill,  which  is  followed  by  moderate  fever.  There  is  intense 
pain  in  the  back  radiating  along  the  course  of  the  nerves. 
The  back  is  exquisitely  tender.  The  spinal  muscles  are  rigid 
and  contracted,  sometimes  so  much  so  as  to  induce  opisthot- 
onos. The  reflexes  are  increased.  When  the  exudate  is 
sufficient  to  make  considerable  pressure  on  the  cord,  paralytic 
phenomena  develop,  such  as  slight  anaesthesia  and  partial 
paralysis  of  the  extremities. 

There  are  no  cerebral  symptoms  unless  the  meninges  of  the 
brain  are  involved. 

Diagnosis.  Myelitis. — In  this  affection  there  are  marked 
paralysis  and  anaesthesia;  involvement  of  the  bladder  and 
rectum  ;   and  the  formation  of  bedsores 

Rheumatism  of  the  Muscles  and  Fibrous  Tissues  of  the  Bach. — 
In  this  condition  the  joints  are  involved;  the  urine  is  highly 
acid ;  the  pain  does  not  follow  the  nerve-trunks ;  and  the 
symptoms  yield  to  the  salicylates. 

Tetanus. — The  presence  of  a  wound  ;  the  absence  of  fever ; 
the  early  involvement  of  the  jaw;  and  the  absence  of  exquisite 
tenderness  in  the  back  will  separate  tetanus  from  meningitis. 

Prognosis. — Extremely  grave.  Recovery  sometimes  fol- 
lows, but  rarely  without  partial  paralysis. 

Chronic  Leptomeningitis. — Pain  in  the  back;    stiffness  of 


CHEONIC  SPINAL,  PACHYMENINGITIS.  353 

muscles ;  hypersesthesia  and  parsesthesia  of  the  lower  extremi- 
ties, but  rarely  any  anaesthesia ;  some  loss  of  power ;  and 
increased  reflexes. 

Treatment. — An  ice-bag,  leeches,  or  cups  may  be  applied 
to  the  spine.  Sedatives  like  chloral,  bromides,  and  morphine 
are  usually  required.  Warm  baths  relieve  the  pain  and  lessen 
the  rigidity.     Ergot  and  iodide  of  potassium  are  recommended. 

If  the  acute  symptoms  subside,  iodide  of  potassium  may  be 
administered  internally ;  blisters  and  mercurial  inunctions 
may  be  applied  to  the  spine,  and  massage  and  electricity  to 
the  affected  muscles. 

CHKONIC  SPINAL  PACHYMENINGITIS. 

(Cervical  Hypertrophic  Pachymeningitis,  Internal 
Pachymeningitis . ) 

Definition. — A  chronic  inflammatory  affection  of  the  dura 
mater,  characterized  by  severe  pains  in  the  head,  shoulders, 
arms,  and  loins,  followed  by  paresis,  wasting,  and  anaesthesia. 

Etiology. — Male  sex,  middle  life,  prolonged  exposure  to 
cold,  lowered  vitality,  spinal  concussion,  alcoholism,  and  syphih's 
are  predisposing  factors.  It  may  be  secondary  to  inflammation 
of  neighboring  structures,  such  as  the  vertebrae  in  Pott's 
disease. 

Pathology. — The  membranes  are  thickened,  opaque,  and 
adherent ;  the  vessels  are  dilated ;  and  the  spinal  fluid  is  in- 
creased. In  advanced  cases  the  membranes  are  glued  together 
and  form  a  thick,  homogeneous,  fibrous  mass.  The  cervical 
region  is  most  commonly  affected.  The  inflammation  may 
extend  to  the  cord  and  peripheral  nerves. 

Symptoms. — Sharp  pains  radiating  into  the  head,  shoulders, 
arms,  and  loins,  followed  by  loss  of  power,  anaesthesia,  wast- 
ing, and  rigidity,  particularly  in  the  upper  extremities.  When 
the  lower  part  of  the  cord  is  involved  the  same  phenomena 
are  observed  in  the  legs,  and  the  knee-jerk  is  increased.  The 
duration  of  the  disease  is  several  years. 

Diagnosis.  —  Chronic  Poliomyelitis. — The  absence  of  pain 
and  of  anaesthesia  will   separate  poliomyelitis   from  pachy- 
meningitis. 
23 


354  DISEASES   OF  THE   NERVOUS  SYSTEM. 

Multiple  Neuritis. — In  this  affection  the  pain  is  less  marked 
in  the  back  and  more  marked  in  the  extremities,  and  the  nerve- 
trunks  are  tender  on  pressure. 

Spinal  Irritation. — In  this  condition  the  spine  is  tender  at 
certain  ^pots,  and  there  is  no  radiating  pain,  anaesthesia,  or 
wasting. 

Prognosis. — This  depends  on  the  extent  and  cause.  When 
the  involvement  is  slight  or  is  due  to  syphilis,  the  prognosis 
should  be  guardedly  favorable. 

Treatment. — Absolute  rest.  Tonics  are  often  indicated. 
Counter-irritation  should  be  made  along  the  cord  by  frequent 
blisters  or  the  actual  cautery.  Morphine,  antipyrin,  or  phena- 
cetin  may  be  required  for  the  relief  of  pain.  Iodide  of  potas- 
sium may  be  administered  for  its  absorbent  effect,  and  in 
syphilitic  cases  it  should  be  given  freely  in  conjunction  with 
some  mercurial. 

ACUTE  MYELITIS. 

Definition. — An  acute  inflammation  of  the  substance  of 
the  cord,  characterized  by  marked  disturbances  of  motion,  sen- 
sation, and  nutrition. 

Varieties. — When  only  a  transverse  section  is  involved 
the  condition  is  termed  transverse  myelitis.  When  a  large 
vertical  section  is  affected  the  disease  is  termed  diffuse  myelitis. 
When  the  gray  matter  is  especially  involved  it  is  termed  centi^al 
myelitis. 

Etiology. — Traumatism ;  exposure  to  cold,  especially  when 
the  body  is  overheated ;  over-exertion;  alcoholism;  syphilis;  or 
the  infectious  fevers  may  induce  it.  It  is  sometimes  secondary 
to  a  hemorrhage  or  a  morbid  growth  in  the  cord. 

Pathology. — The  membranes  are  usually  injected  and 
opaque.  The  substance  of  the  cord  is  red  and  soft,  and  the 
line  of  demarcation  between  the  gray  and  white  matter  is  in- 
distinct. In  very  acute  cases  the  substance  of  the  cord  may 
flow  out  as  a  reddish,  creamy  fluid  when  the  membranes  are 
cut.  Occasionally  there  are  conspicuous  hemorrhagic  effusions 
(hsematomyelitis). 

Microscopic  examination  reveals  destruction  of  the  nerve- 


ACUTE   MYELITIS.  355 

elements,  and  in  their  place  granular  debris,  fat-globules,  red 
blood -corpuscles,  and  leucocytes. 

Symptoms.  Acute  Transvei^se  Myelitis. — Moderate  fever 
(101°-103°),  loss  of  appetite,  coated  tongue,  and  constipa- 
tion, followed  by  pain  in  the  back  radiating  into  the  limbs. 
With  the  pain  there  are  often  various  forms  of  parsesthesia, 
as  numbness,  tingling,  burning,  etc.  The  muscles  may  be  the 
seat  of  tremors  or  of  convulsive  seizures.  There  is  frequently 
a  sense  of  painful  constriction — "  girdle  pain" — at  the  level  of 
the  disease.  Paralysis  soon  develops,  and  may  become  more 
or  less  complete.  The  reflexes  are  generally  increased  when 
the  lesion  is  above  the  lumbar  enlargement ;  but  if  the  latter 
is  involved  they  are  lost.  The  paralyzed  muscles  are  flabby, 
but  do  not  yield  the  reactions  of  degeneration ;  when,  how- 
ever, the  reflexes  are  exaggerated  the  muscles  often  become 
rigid  and  contracted.  At  first  there  may  be  retention  of 
urine  and  feces,  but  later  there  is  frequently  incontinence. 
Anaesthesia  is  more  or  less  complete.  Bedsores  soon  develop 
and  add  to  the  distress  of  the  patient. 

Death  may  result  in  a  few  days  from  extension  upward  and 
involvement  of  the  respiratory  muscles.  In  many  cases  life 
is  prolonged  for  several  weeks,  death  finally  resulting  from 
exhaustion  induced  by  bedsores  and  cystitis.  In  rare  cases 
there  is  a  spontaneous  arrest  of  the  inflammation,  and  slow 
recovery  follows,  attended  with  partial  paralysis. 

Acute  Central  Myelitis  — This  resembles  the  former,  but  the 
trophic  disturbances  are  much  more  marked  and  the  dura- 
tion is  shorter.  The  disease  is  characterized  by  moderate  fever 
and  its  associated  phenomena,  pain  in  the  back,  complete  loss 
of  power  and  of  sensation,  loss  of  reflexes,  incontinence  of 
urine  and  feces,  rapid  wasting  of  the  muscles,  and  the  early 
development  of  bedsores.  The  disease  invariably  proves 
fatal  in  from  one  to  two  weeks. 

Diagnosis.  Acute  Poliomyelitis. — In  this  disease  the  blad- 
der and  rectum  are  not  involved,  and  there  are  no  sensory 
disturbances. 

Landry^ s  Disease,  or  Acute  Ascending  Paralysis. — In  this 
affection  trophic  disturbances  are  absent;  the  bladder  and 
rectum  are  not  involved ;  and  the  loss  of  sensation  is  slight. 


356  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Multiple  Neuritis, — The  "girdle  pain"  is  absent ;  the  sphinc- 
ters are  not  aiFected  ;  bedsores  are  rare  ;  and  pain  is  more 
marked  in  the  extremities  than  in  the  back. 

Meningitis — The  girdle  pain  is  absent ;  the  sphincters  are 
not  affected  ;  the  irritative  phenomena  are  more  marked  than 
the  paralytic. 

Hemorrhage  into  the  Cord. — The  paralysis  develops  ab- 
ruptly. 

Prognosis.  —  Always  extremely  grave.  Acute  central 
myelitis  is  invariably  fatal.  In  other  cases  recovery  attended 
with  partial  paralysis  occasionally  follows. 

Treatment. — If  possible,  the  patient  should  be  placed  on 
a  water-bed.  To  delay  the  formation  of  bedsores  extreme 
cleanliness  is  essential.  Both  in  retention  and  incontinence  of 
urine  the  catheter  should  be  used  twice  daily.  In  incontinence 
of  urine  and  feces  the  discharges  should  be  received  on  cotton- 
wool or  oakum,  which  should  be  frequently  renewed  and  the 
parts  thoroughly  cleansed.  In  the  beginning  an  ice-bag  or 
wet  cups  may  be  applied  to  the  spine.  Such  remedies  as  ergot, 
belladonna,  quinine,  and  mercury  are  frequently  employed,  but 
they  seem  to  exert  little  influence.  If  recovery  should  follow, 
massage,  electricity,  and  strychnine  may  be  employed  with  the 
hope  of  restoring  power  to  the  paralyzed  muscles. 

CHRONIC  MYELITIS. 

Etiology. — Middle  life,  continued  exposure  to  cold  and 
wet,  syphilis,  alcoholism,  gout,  traumatism,  and  excesses  are  the 
predisposing  factors.     It  may  be  secondary  to  Pott's  disease. 

Pathology". — The  membranes  are  opaque  and  adherent. 
The  whole  cord  has  a  grayish  color ;  it  is  firmer  than  normal 
and  somewhat  contracted. 

Microscopic  examination  reveals  destruction  of  nerve-ele- 
ments, and  their  replacement  by  an  overgrowth  of  connective 
tissue. 

Symptoms. — The  disease  begins  gradually  with  numbness, 
tingling,  or  burning  in  the  lower  extremities,  followed  by  a  loss 
of  power  and  sensation.  The  reflexes  are  generally  exagger- 
ated.    The  sphincters  soon  become  involved.     The  muscles  do 


SCLEROSIS   OF   THE  SPINAL   COED.  357 

not  waste  until  the  disease  is  far  advanced.  As  in  other 
organic  affections  of  the  cord,  there  is  often  a  sense  of  constric- 
tion, or  "girdle  pain,"  at  the  level  of  the  disease.  The  disease 
progresses  very  slowly,  the  duration  being  from  six  months  to 
ten  years. 

Diagnosis. — The  diagnosis  rests  on  the  gradual  develop- 
ment of  symptoms  indicating  a  general  involvement  of  the 
cord. 

Treatment. — The  patient  should  be  put  at  rest;  tonics 
are  often  indicated ;  counter-irritation  to  the  spine  by  repeated 
blisters  or  applications  of  the  actual  cautery,  often  yields  good 
results.  The  frequent  use  of  tepid  baths  is  also  beneficial. 
The  special  remedies  which  have  been  recommended  are 
arsenic,  strychnine,  phosphorus,  nitrate  of  silver,  mercury,  and 
iodide  of  .potassium.  When  there  is  a  suspicion  of  syphilis 
the  last  two  remedies  should  be  given  a  thorough  trial. 

SCLEROSIS  OF  THE  SPHSTAE  CORD. 

(Duchenne's  Disease.) 

Definition. — A  degenerative  affection  of  the  spinal  cord, 
characterized  anatomically  by  an  atrophy  of  the  nerve-elements 
and  an  overgrowth  of  connective  tissue. 

Etiology. — Middle  life,  male  sex,  syphilis,  alcoholism, 
mineral  poisoning,  excesses,  and  continued  exposure  to  cold 
and  wet  are  the  usual  causes. 

Locomotor  Ataxia. 

(Locomotor  Ataxy,  Tabes  Dorsalis,  Posterior  Sclerosis.) 

Definition. — A  sclerosis  affecting  the  posterior  columns 
of  the  cord,  and  characterized  by  incoordination,  loss  of  deep 
reflexes,  disturbances  of  nutrition  and  of  sensation,  and  various 
ocular  phenomena. 

Pathology. — The  membranes  over  the  posterior  columns 
are  often  opaque  and  adherent.  The  posterior  columns  have 
a  grayish  color,  and  are  firm  and  shrunken. 

Microscopic  examination  reveals  atrophy  of  the  nerve- 
fibres  and  an  overgrowth  of  connective  tissue.     Degenerative 


358  DISEASES   OF  THE   NERVOUS  SYSTEM. 

changes  are  frequently  observed  in  the  basal  ganglia  and  in 
the  peripheral  nerves. 

Symptoms.  Motor  Phenomena.  —  One  of  the  earliest 
symptoms  is  loss  of  coordination.  This  is  first  manifested 
by  unsteadiness  when  the  patient  walks  in  the  dark.  When 
he  stands  erect,  with  the  eyes  closed  and  feet  together,  he 
staggers  and  tends  to  fall  (Romberg's  symptom).  When  the 
arms  are  affected  there  is  inability  to  perform  work  requiring 
delicate  coordination,  such  as  writing  and  piano-playing. 
This  loss  of  coordination  in  the  upper  extremities  becomes 
conspicious  when  the  patient,  while  his  eyes  are  closed,  at- 
tempts to  touch  the  tip  of  his  nose. 

The  gait  is  characteristic ;  in  walking  he  raises  his  feet  high, 
throws  them  forwards,  and  brings  them  down  forcibly  in  such 
a  way  that  the  whole  sole  strikes  the  floor  at  once.  Although 
the  patient  may  be  unable  to  walk  or  to  use  his  hands  with 
precision,  there  is  no  actual  loss  of  power. 

Sensory  Phenomena. — Pain  is  rarely  absent ;  it  is  sharp  and 
lancinating  in  character,  and  appears  in  paroxysms.  It  usually 
involves  the  extremities,  but  sometimes  it  attacks  the  stomach 
and  is  accompanied  with  obstinate  vomiting.  The  term  gastric 
crisis  is  applied  to  this  phenomenon. 

Crises  may  occur  in  other  organs,  notably  the  larynx,  where 
they  are  manifested  by  intense  dyspnoea  and  stridulous  breath- 
ing. Various  forms  of  paresthesia  are  observed,  such  as 
tingling,  numbness,  "  pins  and  needles,"  and  the  like.  Irregu- 
lar areas  of  anaesthesia  are  frequently  distributed  over  the  body. 

Reflexes. — ^The  patellar  reflex  is  lost  very  early  in  the 
disease.  The  pupil  fails  to  respond  to  light  while  it  still 
accommodates  for  distance  (Argyll-Robertson  pupil). 

Eye  Phenomena. — The  most  important  are  diplopia,  con- 
tracted pupils,  dimness  of  vision  from  optic  atrophy,  and 
paresis  of  the  ocular  muscles. 

Trophic  Phenomena. — The  most  curious  are  the  so-called 
arthropathies,  which  consist  of  enlargement  of  the  joints, 
associated  with  serous  effusions,  atrophy  of  the  heads  of  the 
bone,  erosion  of  the  cartilages,  and  calcification  of  the  liga- 
ments.    These  articular  changes  sometimes  lead  to  luxations. 

Perforating  ulcer  of  the  foot  is  sometimes  observed. 


SCLEROSIS  OF  THE  SPINAL  COED.  359 

Other  symptoms  sometimes  observed  are :  loss  of  sexual 
power,  paralysis  of  the  sphincters,  epileptiform  seizures,  and 
dementia. 

Diseases  with  which  locomotor  ataxia  may  be  asso- 
ciated.— Spastic  paraplegia,  multiple  neuritis,  paretic  demen- 
tia, and  chronic  poliomyelitis. 

Diagnosis.  Multiple  Neuritis.  —  In  this  affection  the 
peripheral  nerves  are  tender;  the  muscles  may  yield  the 
reactions  of  degeneration ;  the  pain  is  not  lancinating  like 
that  of  ataxia ;  and  the  Argyll-Robertson  pupil  is  absent. 

Tumor  of  the  Cerebellum. — In  this  condition  the  reflexes  are 
not  abolished,  lightning  pains  are  absent,  and  instead  there 
are  persistent  vomiting,  headache,  and  optic  neuritis. 

Gastralgia. — A  gastric  crisis  may  be  mistaken  for  gastralgia, 
but  the  associated  phenomena  of  locomotor  ataxia  will  prevent 
an  error  in  diagnosis. 

Prognosis. — Generally  unfavorable,  although  arrest  and 
even  improvement  are  not  infrequent.  The  duration  is  in- 
definite. 

Treatment. — The  patient  should  be  placed  under  the  best 
hygienic  conditions.  Rest  is  desirable.  In  the  early  stage  a 
prolonged  voyage  may  produce  excellent  results.  The  diet 
must  be  nutritious,  but  easily  assimilable.  Excesses  of  all 
kinds  must  be  rigidly  prohibited.  Tonics  are  frequently  in- 
dicated. When  there  is  a  suspicion  of  syphilis,  iodide  of 
potassium  should  be  given  in  full  doses.  In  other  cases  iodide 
of  potassium  in  small  doses,  mercury,  and  arsenic,  are  the 
most  reliable  remedies.  The  following  pill  may  prove 
useful : — 

1^   Sodii  arsenat., 

Zinc,  phosphid.,  aa  gr.  ij  ; 

Hj'^drarg.  iodid.  rub.,  gr.  j. — M. 
'Ft.  in  pil.  ISTo.  xxx. 
Sig. — One,  three  times  daily  after  meals. 

Counter-irritation  to  the  spine  is  useful  and  may  be  made 
with  small  blisters  or  the  actual  cautery. 

The  Pains. — When  very  intense,  morphine  will  be  required ; 
in  other  cases  antipyrin,  phenacetin,  and  cannabis  indica  are 
sometimes  efficient. 


360  DISEASES   OF   THE   NERVOUS  SYSTEM. 

^  Antipyrin,  sj  ; 
Syr.  zingibei'.,  f^j  ; 

Aqu8e  q.  s.  ad  ^iv. — M.     (Germain  See.) 
Sig. — A  teaspoonful  every  one  to  four  hours  for  three  to  six 
doses. 

The  laryngeal  crises  may  be  relieved  by  the  inhalation  of 
chloroform  or  amyl  nitrite. 

Primary  Spastic  Paraplegia. 

(Lateral  Sclerosis,  Antero-lateral  Sclerosis.) 

Definition. — A  nervous  affection  probably  dependent 
upon  sclerosis  of  the  lateral  columns,  and  characterized  by 
loss  of  power,  increased  reflexes,  and  a  spastic  condition  of  the 
muscles. 

Pathology. — There  is  probably  a  sclerosis  of  the  lateral 
columns  of  the  cord. 

Symptoms. — Loss  of  power  is  generally  the  first  symptom. 
This  begins  in  the  lower  extremities  and  increases  very  slowly. 
The  knee-jerk  is  exaggerated,  and  in  most  cases  ankle-clonus 
can  be  elicited.  When  put  in  use  the  muscles  become  stiff,  or 
spastic,  and  when  the  disease  is  fully  developed  the  gait  is 
peculiar.  In  walking  the  knees  are  drawn  together,  the  legs 
drag  behind,  and  the  toes  catch  the  ground. 

The  muscles  do  not  waste,  but  rather  tend  to  become  hyper- 
trophied  from  continued  reflex  stimulation.  The  sphincters 
are  ultimately  affected.  Sensation  is  generally  undisturbed, 
but  subjective  phenomena  like  numbness  and  tingling  may  be 
observed.  The  upper  extremities  are  not  often  involved,  but 
finally  loss  of  power  and  rigidity  may  develop  in  them  also. 

Prognosis. — Unfavorable.  In  rare  instances  the  disease  is 
arrested. 

The  duration  is  indefinite. 

Treatment. — The  general  treatment  is  the  same  as  in 
locomotor  ataxia.  For  the  spasmodic  condition  of  the  mus- 
cles, rubbing,  warm  baths,  and  the  following  remedies  are 
recommended :  bromide  of  potassium,  calabar  bean,  and  bel- 
ladonna. 


SCLEROSIS   OF   THE  SPINAL  COED.  361 

Amyotrophic  Lateral  Sclerosis. 

Definition. — A  nervous  affection  characterized  anatomi- 
cally by  a  degeneration  of  the  lateral  columns  and  adjacent 
.  gray  matter,  and  manifested  clinically  by  loss  of  power, 
wasting,  and  a  spastic  condition  of  the  muscles. 

Pathology. — The  disease  apparently  depends  upon  a 
sclerosis  involving  mainly  the  anterior  horns  of  the  gray  matter 
and  the  antero-lateral  columns* 

Symptoms. — Loss  of  power  and  wasting,  usually  beginning 
in  the  small  muscles  of  the  hand,  and  gradually  spreading  over 
the  entire  body.  The  reflexes  are  exaggerated.  When  the 
muscles  are  put  into  use,  they  become  more  or  less  rigid,  or 
spastic.  The  degenerative  process  extends  upwards  until  it 
involves  the  medulla,  when  symptoms  of  bulbar  palsy  appear. 

Diagnosis. — The  muscular  rigidity  and  exaggerated  reflexes 
will  distinguish  it  from  pure  'progressive  muscular  atrophy. 

Prognosis. — Unfavorable. 

Treatment.  —  Such  remedies  as  arsenic  and  iodide  of 
potassium  are  recommended,  but  they  usually  prove  useless. 
The  spastic  condition  is  improved  by  massage. 

Ataxic  Paraplegia. 

Definition. — A  sclerotic  affection  of  the  posterior  and 
lateral  columns  manifesting  symptoms  of  both  locomotor  ataxia 
and  spastic  paraplegia. 

Symptoms. — It  resembles  spastic  paraplegia  in  the  loss  of 
power,  spastic  condition  of  the  muscles,  increased  reflexes,  and 
absence  of  sensory  disturbances ;  and  locomotor  ataxia  in  the 
distinct  loss  of  coordination. 

Disseminated  Cerebro- spinal  Sclerosis. 

(Multiple  Sclerosis,  Insular  Sclerosis.) 

Definition. — A  chronic  nervous  disease  characterized  ana- 
tomically by  patches  of  sclerosis  of  varying  size  scattered 
through  the  brain  and  cord. 

Etiology. — The  causes  which  lead  to  other  scleroses  of  the 
cord  may  induce  this  disease ;  the  infectious  fevers,  however. 


362  DISEASES  OF  THE   NERVOUS  SYSTEM. 

are  assigned  a  prominent  place  in  its  etiology.  It  is  more 
commonly  observed  in  younger  people  than  is  locomotor  ataxia 
or  lateral  sclerosis. 

Patholgy. — Areas  of  firm,  gray,  sclerotic  tissue,  of  various 
sizes  and  shapes,  are  found  through  the  brain  and  cord. 

Symptoms. — The  spinal  symptoms  may  resemble  either 
locomotor  ataxia  or  lateral  sclerosis,  according  as  the  posterior 
or  lateral  columns  are  chiefly  affected.  The  characteristic 
symptoms  are  loss  of  power,  usually  most  marked  in  the  legs ; 
increased  reflexes ;  vague  pains ;  a  coarse  tremor  developed  on 
movement  (volitional  tumor) ;  a  slow,  hesitating,  "  scanning"<;^ 
speech  ;  nystagmus — tremor  of  the  eyeballs ;  and  mental  im- 
pairment. Sensory  and  trophic  disturbances  are  generally 
absent. 

Diagnosis. — Disseminated  sclerosis  may  be  mistaken  for 
paralysis  agitans,  but  the  latter  disease  develops  in  late  life ; 
the  tremor  is  fine,  rarely  involves  the  head,  and  is  not  made 
worse  by  use  of  the  muscles ;  and  nystagmus  is  absent. 

Prognosis. — Unfavorable.  The  duration  is  indefinite,  and 
long  remissions  with  improvement  of  the  symptoms  are  not 
uncommon. 

Treatment. — The  general  treatment  is  the  same  as  that 
for  posterior  sclerosis.  Bromides,  hyoscine,  hyoscyamine,  and 
belladonna  have  been  recommended  for  the  tremors. 

Hereditary  Ataxia. 

(Friedreich's  Disease.) 

Definition. — A  sclerotic  affection  of  the  spinal  cord,  occur- 
ring in  several  children  of  the  same  family,  and  characterized 
by  symptoms  resembling  locomotor  ataxia. 

Etiology. — The  greatest  number  of  cases  develop  between 
the  second  and  fifteenth  years.  Some  can  be  traced  to  heredi- 
tary influence ;  in  others  a  cause  cannot  be  ascertained. 

Pathology — Sclerosis  of  the  posterior  and  lateral  columns 
cf  the  cord. 

Symptoms. — Loss  of  coordination  in  the  arm  and  legs, 
nystagmus,  irregular  jerking  movements  of  the  hands,  loss  of 


ACUTE   ANTERIOR  POLIOMYELITIS.  363 

reflexes,  a  scanning  speech,  spinal  curvature,  equino-varus  (heel 
raised  and  the  sole  turned  in). 

It  differs  from  locomotor  ataxia  in  the  absence  of  sharp 
pains,  of  anaesthesia,  and  of  the  Argyll-Robertson  pupil,  and 
in  the  occurrence  of  irregular  movements  of  the  hands,  nystag- 
mus, scanning  speech,  and  equino-varus. 

Prognosis. — Unfavorable.     The  duration  is  many  years. 

SYRINGO-MYELIA. 

Definition. — A  cavernous  condition  of  the  gray  matter  of 
the  spinal  cord  associated  with  an  overgrowth  of  the  neuroglia 
and  more  or  less  degeneration  of  the  surrounding  tissue. 

Etiology. — The  disease  is  probably  of  congenital  origin, 
although  it  may  not  manifest  itself  until  adult  life. 

Symptoms. — Paralysis  and  wasting  of  the  muscles,  especially 
of  the  upper  extremities ;  spinal  curvature ;  a  loss  of  painful 
and  thermic  sensation,  while  tactile  sensation  is  preserved,  are 
the  chief  phenomena.  Symptoms  of  lateral  or  of  posterior 
sclerosis  are  generally  present.  Trophic  disturbances,  such  as 
arthropathies,  ulcers,  and  gangrene,  are  not  infrequent. 

Diagnosis.  Chronic  Poliomyelitis. — In  this  affection  there 
are  no  sensory  disturbances. 

llorvan's  Disease. — This  disease  closely  resembles  syringo- 
myelia, but  tactile  sensation  is  lost  and  there  is  a  marked 
tendency  to  painless  whitlows. 

Prognosis. — Unfavorable,     Duration,  several  years. 

ACUTE  ANTERIOR  POLIOMYELITIS. 

(Infantile   Paralysis,  Atrophic  Spinal  Paralysis.) 

Definition.  —  An  acute  disease,  occurring  almost  exclu- 
sively in  young  children,  characterized  anatomically  by  a  de- 
struction of  the  ganglion-cells  in  the  anterior  gray  horns  of  the 
cord,  and  manifested  clinically  by  abrupt  paralysis  and  rapid 
wasting  of  certain  muscles. 

Etiology.  —  The  greatest  number  of  cases  occur  within 
the  first  three  years,  and  the  disease  is  far  more  common  in 
summer  than  in  winter.     The  sudden  onset,  the  absence  of 


364  DISEASES   OF   THE   NERVOUS  SYSTEM. 

any  known  exciting  cause,  and  the  fact  that  it  has  occurred 
epidemically  suggest  an  infectious  origin. 

Pathology.  —  The  sudden  onset  and  wide-spread  initial 
paralysis  are  probably  due  to  intense  congestion,  and  the  per- 
manent paralysis  and  wasting  to  destruction  of  the  ganglion- 
cells  in  the  anterior  gray  horns.  Microscopic  examination  in 
recent  cases  reveals  ecchymoses,  destruction  of  ganglion-cells, 
and  infiltration  of  leucocytes. 

Examination  long  after  the  development  of  the  paralysis 
reveals  an  absence  or  atrophy  of  the  large  multipolar  cells 
in  the  gray  horns,  and  in  their  stead  an  overgrowth  of  connec- 
tive tissue.  The  anterior  nerve-roots  and  muscles  also  reveal 
degenerative  changes. 

Symptoms. — Generally  the  onset  is  abrupt ;  often  the  child 
is  put  to  bed  in  apparent  health  and  in  the  morning  is  found 
paralyzed  in  one  or  more  limbs.  In  some  cases  febrile  symp- 
toms precede  the  attack,  and  more  rarely  the  disease  is  ushered 
in  with  a  chill,  a  convulsion,  or  delirium. 

The  paralysis  at  first  may  be  quite  exteusive,  but  more  com- 
monly it  confines  itself  to  certain  groups  of  muscles  in  the 
upper  and  lower  extremities.  The  latter  are  especially  prone  to 
suffer ;  the  affected  muscles  are  relaxed,  and  the  surface  is  cold 
and  often  cyanosed.  The  paralysis  is  peculiar  in  its  irregular 
distribution  and  in  its  tendency  to  improve  spontaneously  up  to 
a  certain  limit.  There  are  no  sensory  disturbances,  no  involve- 
ment of  the  bladder  and  rectum,  and  no  tendency  to  bedsores. 
The  muscles  which  are  permanently  affected  rapidly  waste  and 
yield  the  reactions  of  degeneration.  From  contractures  of  the 
atrophied  muscles  and  contraction  of  their  healthy  antagonists, 
various  deformities  develop. 

Diagnosis. — The  abrupt  onset  will  distinguish  it  from  both 
idiopathic  muscular  atrophy  and  progressive  muscular  atrophy. 
The  absence  of  sensory  disturbances,  bedsores,  and  paralysis 
of  the  bladder  and  rectum  will  separate  it  from  myelitis.  The 
presence  of  cerebral  symptoms,  of  choreiform  or  athetoid 
movements  in  the  affected  members,  and  the  absence  of  reac- 
tions of  degeneration  and  of  early  wasting  will  separate  cere- 
bral paralysis  of  childhood  from  acute  poliomyelitis. 


PEOGEESSIVE   MUSCULAR   ATROPHY.  365 

Prognosis. — Unless  the  initial  symptoms  are  very  severe, 
the  prognosis,  as  regards  life,  is  good.  *  In  all  cases  some  of 
the  paralysis  disappears.  Occasionally  the  improvement  is  so 
great  that  the  usefulness  of  the  member  is  not  impaired  ;  but 
far  more  frequently  the  residual  paralysis  is  sufficient  to  cause 
considerable  deformity  and  disability. 

Treatment. — During  tlie  acute  stage  the  child  should  be 
confined  to  bed.  To  relieve  the  congestion,  dry  cups  may  be 
applied  to  the  spine  and  ergot  may  be  given  internally.  The 
aifected  members  should  be  wrapped  in  flannel. 

After  the  lapse  of  two  or  three  weeks  electrical  treatment 
should  be  instituted ;  the  faradic  current  may  be  employed 
M'hen  it  induces  contraction  of  the  aifected  muscles,  but  when 
it  excites  no  response  the  galvanic  current  must  be  substituted. 
Massage  is  a  very  valuable  adjunct  to  the  electrical  treatment. 
Internally  strychnine  (gr.  ywo  ^'^  ^  child  of  two  years)  gradually 
increased  is  a  useful  muscular  stimulant.  Massage  and  the 
adjustment  of  mechanical  appliances  will  be  required  to  combat 
deformity  from  contractures. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

(Chronic  Spinal  Muscular  Atrophy,  Chronic  Poliomyelitis.) 

Definition. — A*chronic  nervous  affection,  characterized 
anatomically  by  degeneration  of  the  ganglion-cells  of  the  gray 
matter  in  the  cord,  and  manifested  clinically  by  loss  of  power 
and  atrophy  of  corresponding  muscles. 

Etiology, — Male  sex,  middle  life,  and  hereditary  tendency 
are  the  predisposing  causes.  It  sometimes  follow  prolonged 
emotional  excitement,  exposure  to  cold,  traumatism,  and 
syphilis. 

Pathology. — Microscopic  examination  of  the  gray  matter 
of  the  cord  reveals  atrophy  or  complete  absence  of  the  large 
multipolar  cells  in  the  anterior  cornua,  and  an  overgrowth  of 
connective  tissue.  The  anterior  root-fibres  are  also  the  seat  of 
degenerative  changes.  In  some  cases  the  lateral  columns  are 
likewise  sclerosed  (amyotrophic  lateral  sclerosis). 

Examination  of  the  affected  muscles  reveals  atrophy  of  the 
fibres,  fatty  degeneration,  an  overgrowth  of  connective  tissue, 


366  DISEASES   OF   THE   NERVOUS  SYSTEM. 

and  an  absence  of  transverse  striation,  and  instead,  longitudi- 
nal striation. 

Symptoms. — Not  infrequently  prodromal  symptoms  are 
noted  in  the  parts  to  be  affected,  such  as  pain,  coldness,  or 
numbness.  Soon,  loss  of  power  and  wasting  begin  in  the 
small  muscles  of  the  hand,  namely,  the  thenar  and  interossei 
muscles.  Although  one  hand  is  usually  affected  before  the 
other,  the  disease  tends  to  become  symmetrical.  Next  to  the 
hands  the  muscles  of  the  shoulders  and  arms  slowly  waste,  ren- 
dering the  bony  prominences  marked  ;  and  so  the  disease 
advances  little  by  little  until  the  patient  is  reduced  to  a  mere 
skeleton.  The  hands  assume  a  characteristic  appearance  :  from 
atrophy  of  the  interossei  and  contraction  of  the  long  extensor  and 
flexor  muscles  they  become  "  claw-like."  The  wasted  mus- 
cles are  frequently  the  seat  of  fibillary  tremors.  The  response 
to  the  galvanic  and  faradic  currents  is  diminished,  but  the  re- 
actions of  degeneration  do  not  develop  until  the  disease  is  far 
advanced.  Although  the  patient  may  complain  of  coldness 
and  numbness,  sensation  is  not  impaired.  The  legs  are  not 
involved  until  late,  and  often  escape  entirely. 

The  wasting  progresses  very  slowly,  and  death  may  result 
from  some  intercurrent  disease ;  if  such  is  not  the  case,  exten- 
sion to  the  medulla  leads  to  symptoms  of  bulbar  palsy,  such  as 
indistinct  articulation,  inability  to  pucker  the  lips,  difficult 
swallowing,  and  embarrassed  respiration. 

Complications. — It  may  be  associated  with  lateral  sclerosis, 
when  it  is  termed  amyotrophic  lateral  sclerosis.  It  may  lead  to 
bulbar  palsy. 

Diagnosis.  Primary  Muscular  Atrophy. — This  disease 
develops  in  earlier  life,  rarely  begins  in  the  hand,  and  the 
hereditary  tendency  is  more  marked  than  in  poliomyelitis. 

Prognosis. — Always  unfavorable.  The  duration  is  indefi- 
nite. 

Treatment. — Good  hygiene.  Nutritious  food.  Tonics. 
Gowers  claims  good  resuUs  from  the  hypodermic  injection  of 
nitrate  of  strychnine  (gr.  ^-^-g-  increased  to  -^q)  once  daily. 
Massage  and  electricity  yield  no  results. 


ACUTE  ASCENDING  PARALYSIS.  367 

BULBAR  PARAIiYSIS. 

(Glosso-labio-laryngeal  Paralysis.) 

Definition. — Paralysis  of  the  lips,  tongue,  pharynx,  and 
larynx  from  destruction  of  the  ganglionic  cells  of  the  medulla 
oblongata. 

Etiology. — An  acute  form  is  observed  which  results  either 
from  hemorrhage  or  from  an  acute  poliomyelitis  of  the  medulla. 
The  chronic  form,  or  progressive  bulbar  palsy,  may  result 
from  chronic  poliomyelitis  involving  primarily  the  medulla, 
or  from  the  extension  of  the  degenerative  process  in  paretic 
dementia,  amyotrophic  lateral  sclerosis,  progressive  muscular 
atrophy,  or  acute  ascending  paralysis  (Landry's  disease). 

Symptoms. — Impairment  of  speech ;  inability  to  protrude 
the  tongue;  dribbling  of  saliva;  difficult  swallowing;  choking 
spells  from  the  entrance  of  food  or  mucus  into  the  larynx ; 
partial  suppression  of  the  voice  and  measured  speaking ; 
fibrillary  tremors  of  the  lips  and  tongue ;  loss  of  reflex  action  ; 
atrophy  of  the  lips,  tongue,  and  pharynx  ;  and,  finally,  difficult 
respiration  and  disturbed  cardiac  rhythm. 

Prognosis. — Unfavorable.  The  acute  variety  is  speedily 
fatal ;  the  chronic  form  may  last  several  years.  Death  may 
result  from  exhaustion,  cardiac  failure,  or  aspiration-pneu- 
monia. 

Treatment. — Electricity,  strychnine,  and  the  use  of  a 
stomach-tube  when  swallowing  becomes  difficult. 

ACUTE  ASCENDEVG  PAKAJLYSIS. 

(Landry's  Disease.) 

Definition. — An  acute  disease  of  rare  occurrence,  char- 
acterized by  motor  paralysis,  beginning  in  the  feet  and  rapidly 
spreading  until  it  involves  the  muscles  of  respiration  and  deg- 
lutition. 

Etiology. — The  causes  are  unknown.  It  is  usually  ob- 
served in  young  male  adults.  The  abrupt  onset,  acute  course, 
and  absence  of  known  cause  and  of  definite  lesions  have  sug- 
gested an  infectious  origin. 


368  DISEASES   OF  THE  NERVOUS   SYSTEM. 

Pathology. — No  demonstrable  lesions  have  been  discovered. 

Symptoms. — Febrile  symptoms  usually  usher  in  the  attack. 
The  paralysis  begins  in  the  legs  and  involves  successively  the 
trunk,  upj^er  extremities,  and  muscles  of  respiration  and  deg- 
lutition. The  reflexes  are  abolished.  The  sphincters  are 
retentive ;  sensation  is  usually  normal,  but  there  may  be 
parsesthesia  or  some  anaesthesia  ;  the  muscles  are  relaxed,  but 
do  not  waste  or  yield  the  reactions  of  degeneration.  In  some 
instances  the  spleen  and  lymphatic  glands  are  swollen. 

Diagnosis.  Acute  llyelitis. — Anaesthesia,  wasting,  reactions 
of  degeneration,  and  early  involvement  of  the  sphincters  will 
serve  to  distinguish  myelitis  from  acute  ascending  paralysis. 

Multiple  neuritis  will  be  separated  from  Landry's  disease  by 
the  marked  sensory  disturbances  in  the  former. 

Prognosis. — Unfavorable.  The  vast  majority  of  cases  ter- 
minate fatally  in  the  course  of  a  few  days.  Occasionally  there 
is  a  spontaneous  arrest,  and  a  gradual  restoration  to  health. 

Treatment. — Cups  to  the  spine  and  electricity  to  the 
affected  muscles  have  been  employed  with  indifferent  results. 

CAISSON  DISEASE. 

(Divers'  Paralysis.) 

Definition. — A  condition  observed  in  divers  and  others 
subjected  to  increased  atmospheric  pressure,  and  characterized 
by  motor  and  sensory  paralysis  and  other  nervous  symp- 
toms. 

Etiology. — A  pressure  of  more  than  two  atmospheres  is 
required  to  produce  the  paralysis,  and  the  time  elapsing  before 
its  appearance  lessens  as  the  pressure  increases. 

Pathology. — The  symptoms  have  been  ascribed  by  some 
to  the  liberation  in  the  cord  of  gases  which  have  been  absorbed 
by  the  blood  during  exposure  to  the  high  pressure ;  by  others, 
to  stasis  of  blood  and  oedema.  The  cord  is  found  congested 
and  sometimes  the  seat  of  hemorrhages. 

Symptoms. — The  condition  may  manifest  itself  immediately 
on  reaching  the  surface  or  after  the  lapse  of  several  hours. 
The  most  important  phenomena  are  pains  in  the  joints  fol- 
lowed by  motor  and  sensory  paralysis  in  the  lower  extremities. 


IDIOPATHIC  MUSCULAR   ATROPHY.  369 

The  bladder  and  rectum  are  sometimes  involved.  Occasion- 
ally the  paralysis  takes  the  form  of  a  hemiplegia  instead  of  a 
jmraplegia.  Gastralgia  and  vomiting  are  common  symptoms. 
In  severe  cases  coma  develops  and  death  follows  in  a  few  hours. 
Generally,  however,  the  symptoms  gradually  subside,  and  the 
power  is  fully  restored  in  the  course  of  a  few  days  or  a  few  weeks. 
Treatment. — As  a  preventive  measure  the  transition  from 
high  to  low  pressure  should  be  accomplished  gradually. 
Marked  cases  should  be  treated  as  acute  myelitis. 

IDIOPATHIC  MUSCULAR  ATROPHY. 

(Muscular  Dystrophy,  Myopathic  Atrophy.) 

Definition. — An  atrophic  condition  of  the  muscles  de- 
veloping in  early  life  and  not  dependent  upon  any  lesion  in 
the  nervous  system. 

Etiology. — The  disease  usually  manifests  itself  belpre 
puberty.  It  is  more  common  in  males  than  in  females.  It 
is  frequently  transmitted  from  generation  to  generation,  and 
several  members  of  the  same  family  may  be  similarly  affected. 

Pathology. — No  lesion  in  the  cord  or  nerves  is  observed. 
Gowers  regards  the  disease  as  of  developmental  origin.  Micro- 
scopic examination  of  the  muscles  reveals  atrophy  of  their  fibres 
and  an  unnatural  amount  of  fat  and  connective  tissue.  When 
the  latter  elements  are  considerably  increased,  a  pseudo-hyper- 
trophy results  (pseudo-muscular  hypertrophy). 

Symptoms. — The  muscles,  especially  those  of  the  face, 
shoulders,  thighs,  buttocks,  and  calves,  lose  power  and  waste. 
Fibrillary  twitchings  are  rarely  noted.  The  reactions  of  degen- 
ei^ation  are  absent.  In  Erb^s  juvenile  type  the  atrophy  begins 
in  the  shoulder ;  in  the  Landouzy-Dejerine  type,  in  the  face. 

Diagnosis.  Chronic  Poliomyelitis. — This  disease  develops 
later  in  life  without  marked  hereditary  tendency,  and  nearly 
always  begins  in  the  small  muscles  of  the  hands — j^arts  which 
are  rarely  affected  in  idiopathic  atrophy. 

Multiple  Neuritis. — Pain,  aufesthesia,  parsesthesia,  the  his- 
tory, and  the  distribution  of  the  palsy  will  suggest  neuritis. 

Prognosis. — Unfavorable.  The  disease  is  incurable,  but  of 
slow  progress. 

24 


370  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

PSEUDO-HYPERTROPHTC  PABAXYSIS. 

(Pseudo-muscular  Hypertrophy,  Lipomatous  Muscular  Atrophy.) 

Definition. — A  disease  of  childhood,  characterized  by- 
paralysis  depending  upon  degeneration  of  the  muscles,  which, 
however,  become  enlarged  from  a  deposition  of  fat  and  con- 
nective tissue. 

Etiology. — Male  sex,  childhood,  and  an  hereditary  tend- 
ency are  the  only  known  predisposing  causes.  Several  cases 
have  frequently  been  observed  in  the  same  family. 

Pathology. — The  disease  is  allied  to  idiopathic  muscular 
atrophy,  with  which  it  is  frequently  associated.  Since  no 
lesions  are  observed  in  the  cord  or  peripheral  nerves  it  is  to  be 
regarded  as  a  primary  affection  of  the  muscles.  Microscopic 
examination  reveals  an  excessive  amount  of  fat  and  connective 
tissue  between  the  muscle-fibres,  the  latter  being  atrophied  and 
more  or  less  degenerated. 

Symi  TOMS. — The  first  symptom  to  attract  attention  is  weak- 
ness of  the  muscles ;  the  child  is  awkward,  stumbles,  and  in 
walking  seeks  su^aport.  As  the  paralysis  increases,  the  mus- 
cles, particularly  those  of  the  calf,  thigh,  buttock,  and  back, 
enlarge.  The  upper  extremities  are  less  frequently  affected. 
When  the  child  assumes  the  erect  posture  the  feet  are  wide 
apart,  the  belly  protrudes,  and  the  spinal  column  shows  a 
marked  curvature  with  the  convexity  forward.  The  manner 
of  rising  from  the  recumbent  position  is  characteristic :  He 
straightens  himself  either  by  grasping  the  knees,  or  by  resting 
the  hands  on  the  floor  in  front  of  him,  extending  the  legs,  and 
pushing  the  body  backwards.    The  gait  is  waddling  in  character. 

Although  the  response  of  the  muscles  to  electrical  currents  is 
less  pronounced,  the  reactions  of  degeneration  are  not  present. 
The  knee-jerk  is  lessened  or  abolished.  There  are  no  mental 
or  sensory  disturbances. 

In  the  course  of  a  few  years,  the  paralysis  becomes  so  marked 
that  the  patient  is  unable  to  leave  his  bed ;  the  enlargement 
of  the  muscles  is  followed  by  atrophy ;  and  finally  death 
results  from  some  intercurrent  disease,  or  inflammation  of  the 
lungs  induced  by  the  weakened  respiratory  power. 


NEURALGIA.  371 

Prognosis. — Absolutely  unfavorable. 

Treatment. — Remedies  generally  prove  useless.  Graduated 
exercise,  massage,  electricity,  and  hypodermics  of  strychnine 
may  be  employed  with  the  hope  of  staying  the  progress  of  the 
disease. 

NEIIRAI.GIA. 

Definition. — Paroxysmal  pain  radiating  along  the  course 
of  a  nerve-trunk. 

Etiology. — Heredity,  female  sex,  nervous  temperament, 
excesses,  overwork,  and  nervous  exhaustion  are  general  pre- 
disposing factors.  It  is  frequently  an  expression  of  ansemia. 
It  may  result  from  the  action  of  some  toxic  agent  in  the  blood  ; 
thus  it  is  common  in  malaria,  rheumatism,  gout,  syphilis,  and 
chronic  lead-poisoning.  It  may  be  caused  by  reflex  irritation ; 
thus  a  trifacial  neuralgia  may  depend  on  caries  of  the  teeth  or 
eye-strain.  In  some  cases  neuralgia  results  from  organic  dis- 
ease of  the  nerve-centre ;  thus  obstinate  trifacial  neuralgia 
may  be  dependent  uj)on  some  degeneration  or  tumor  of  the 
Gasserian  ganglion. 

Exposure  to  cold  and  wet  frequently  acts  as  an  exciting 
cause  in  susceptible  people. 

Pathology. — The  i)athological  condition  upon  which  neu- 
ralgia depends  is  unknown.  In  many  cases,  no  doubt,  it  is  a 
manifestation  of  neuritis. 

Symptoms. — Certain  prodromes  frequently  give  warning  of 
an  approaching  attack  ;  these  are  chilliness,  depression  of  spirits, 
and  perhaps  tingling  in  the  part  to  be  affected.  The  chief 
symptom  is  intense  pain,  which  is  usually  of  a  sharp,  stabbing 
character.  The  area  supplied  by  the  affected  nerve  is  gener- 
ally hypersesthetic,  and  palpation  detects  spots  of  exquisite 
tenderness  where  the  nerve  makes  its  exit  through  a  bony 
canal  or  fibrous  sheath ;  the  latter  have  been  termed  Valliex's 
points.  In  some  cases  the  pain  is  attended  with  severe  clonic 
or  tonic  spasms  of  the  muscles.  Inspection  of  the  part  usually 
reveals  negative  results,  but  occasionally  distinct  swelling  or 
an  outbreak  of  herpes  is  observed. 

The  attack  lasts  from  a  few  minutes  to  many  hours,  and  its 


372  DISEASES   OF  THE  NERVOUS  SYSTEM. 

subsidence  may  be  marked  by  the  passage  of  a  large  amount 
of  pale  urine.  The  interval  between  the  paroxysms  varies  in 
different  cases ;  it  is  frequently  several  weeks  or  months.  It 
is  noteworthy  that  the  attacks  often  recur  at  regular  intervals. 

Trifacial  Neuralgia  {Tic  Douloureux,  Prosopalgia^ — In  this 
variety  the  pain  involves  one  or  more  branches  of  the  trifacial 
nerve.  The  tender  points  correspond  to  the  supra-orbital, 
infra-orbital,  and  mental  foramina.  Violent  spasms  of  the 
muscles  are  frequently  observed.  In  long-standing  cases  the 
hair  on  the  affected  side  may  become  coarse  and  bleached. 
Trifacial  neuralgia  is  frequently  reflex,  being  dependent  upon 
caries  of  the  teeth,  eye-strain,  nasal  disease,  or  some  distant 
centre  of  irritation. 

Intercostal  Neuralgia. — In  this  variety  the  pain  follows  the 
course  of  the  intercostal  nerves.  It  is  frequently  associated 
with  an  eruption  of  herpes  zoster.  Spots  of  tenderness  may  be 
detected  near  the  vertebral  columns,  in  the  middle  of  the  nerve, 
and  near  the  sternum.  The  frequent  dependence  of  intercostal 
neuralgia  upon  spinal  caries  or  thoracic  aneurism  must  not  be 
forgotten. 

Occipital  neuralgia  involves  the  upper  cervical  nerves.  A 
spot  of  tenderness  may  be  discovered  midway  between  the 
mastoid  process  and  the  upper  cervical  vertebrae.  This  form 
of  neuralgia  may  be  an  expression  of  spinal  caries. 

Sciatica  has  been  described  elsewhere. 

Diagnosis.  Neuritis. — The  continuous  pain,  the  tender- 
ness along  the  entire  nerve,  the  presence  of  paresthesia,  anaes- 
thesia, paresis,  and  wasting  will  serve  to  distinguish  neuritis 
from  neuralgia. 

The  lightning-pains  of  locomotor  ataxia  must  not  be  mis- 
taken for  neuralgia.  The  abolished  patellar  reflex,  the  loss  of 
coordination,  and  the  Argyll-Eobertson  pupil  in  the  former 
will  indicate  the  diagnosis. 

Peognosis. — For  the  attack  the  prognosis  is  good  ;  for  per- 
manent cure,  it  must  be  guarded.  When  the  cause  can  be 
removed  the  prognosis  is  favorable. 

Treatment.  The  Attack. — The  patient  should  be  kept  in 
a  quiet,  cool,  well-ventilated  room.  Local  applications  are 
useful ;   hot   cloths^   stimulating   liniments,   an   ointment   of 


NEURALGIA.  373 

aconitine,  a  small  blister,  or  a  hypodermic  injection  of  cocaine, 
chloroform,  or  morphine  and  atropine  may  be  employed.  One 
of  the  following  applications  will  prove  serviceable  :— 

^  Aconitinse,  gr.  iv; 
Veratrinae,  gr.  xv ; 
Glycerini,  5ij  ; 

Cerati,  3vj.— M.     (Da  CosTA.) 
Sig. — To  be  rubbed  over  the  parts.    Do  not  apply  to  any  abrasion 
of  the  skiu. 

Or— 

^  Chloral,  hydrat., 

Pulv.  camphor.,  aa  ^ss. — M. 
Sig. — Apply  with  a  camel's  hair  brush. 

Internally,  antipyrin,  phenacetin,  cannabis  indica,  bromide  of 
potassium,  butyl  chloral,  and  exalgine  are  efficient  remedies. 
Morphia  is  sometimes  required,  but  the  danger  of  inducing  the 
habit  should  always  be  borne  in  mind. 

Ihe  Interval. — Careful  search  should  be  made  for  an  exciting 
cause,  which,  if  found,  must  be  removed.  The  teeth,  eyes, 
nose,  gastro-intestinal  tract,  urine,  and  blood  should  be  care- 
fully examined. 

In  anaemia,  iron  and  arsenic  are  indicated ;  in  syphilis, 
iodide  of  potassium  ;  in  rheumatism,  salicylate  of  sodium  or 
iodide  of  potassium  ;  in  malaria,  quinine  and  arsenic;  in  gout 
colchicum  and  lithium  ;  in  lead-poisoning,  iodide  of  potassium. 

Tonics  like  iron,  quinine,  strychnine,  cod-liver  oil,  and  phos- 
phorus are  frequently  indicated.  Among  the  special  reme- 
dies may  be  mentioned  arsenic,  velerian,  hyoscyamus,  aconitia, 
gelsemium,  cannabis  indica,  oxide  of  zinc,  nitro-glycerin,  and 
asafoetida.  The  following  pill,  devised  by  Dr.  S.  D.  Gross,  is 
often  very  useful  : — 

^   Quinin.  sulph,,  gj 

Morphin.  sulph., 

Acid,  arsenosi,   aa  gr.  iss  ; 

Ext.  aconiti,  gr.  xv  ; 

Strychnin,  sulph.,  gr.  j.— M. 
Ft.  in  pil.  No.  xxx. 
Sig. — One,  thrice  daily. 

Local  treatment  in  the  interval  may  accomplish  much. 
Electricity,  acupuncture,  or  repeated  blisters  may  be  employed. 


374  DISEASES   OF   THE   NERVOUS  SYSTEM. 

In  obstinate  cases  surgical  interference  may  be  required  to 
secure  relief.  Three  opei'ations  have  been  performed  :  Nerve- 
stretching  ;  neurotomy,  or  section  of  the  nerve ;  and  neurec- 
tomy, or  removal  of  a  portion  of  the  nerve. 

MIGRAINE. 

(Hemicrania,  Megrim,  Sick-headache.) 

Definition. — Paroxysmal  circumscribed  headache  asso- 
ciated with  visual,  vaso-motor,  and  gastric  disturbances. 

Etiology. — It  is  frequently  hereditary.  It  is  more  com- 
mon in  women  than  in  men.  It  usually  develops  in  early  life. 
Anaemia,  gastric  disturbances,  eye-strain,  menstrual  disorders, 
overwork,  and  prolonged  emotional  excitement  predispose  to  it. 

Pathology. — Unknown.  There  is  a  growing  tendency  to 
regard  it  as  a  sensory  epilepsy. 

Symptoms. — The  attack  is  often  preceded  by  malaise,  rest- 
lessness, and  diminished  vision.  The  pain  is  sharp  and 
stabbing  and  frequently  limited  to  the  temporo-frontal  region 
of  one  side.  The  surface  is  extremely  hypersesthetic,  but  the 
tender  spots  noted  in  trifacial  neuralgia  are  absent.  The 
patient  is  very  sensitive  to  light  and  sound,  and  during  the 
attack  usually  confines  herself  to  a  darkened  room.  Nausea 
and  vomiting  are  frequently  present.  In  some  cases  the  tem- 
poral artery  is  contracted,  the  face  is  pale,  and  the  pupil  large  ; 
in  others  the  artery  is  dilated,  the  face  is  flushed,  and  the 
pupil  small.  The  duration  of  the  attacks  varies  from  a  few 
hours  to  several  days.  In  the  intervals,  which  are  often  of 
definite  duration,  the  patient  may  be  quite  well. 

Less  frequent  symptoms  are  vertigo,  hallucinations  of  sight, 
cramps  of  the  facial  muscles,  tingling  or  numbness  in  one 
hand,  partial  aphasia,  and  paresis  of  the  ocular  muscles. 

Prognosis. — Perfect  cure  is  rare,  but  the  severity  and  fre- 
quency of  the  seizures  may  be  considerably  lessened  by  treat- 
ment. 

Treatment.  The  Attack. — Eest  in  a  darkened,  quiet,  and 
well-ventilated  room ;  antipyrin,  caffeine,  bromide  of  potas- 
sium, salol,  and  morphine  with  atropine  are  useful  remedies. 


HEADACHE.  375 

^  Antipyrin,  3j  ; 

Syr.  aurant.  cort.,  f^j  ; 
Aquse,  q.  s.  adf.^iij. — M. 
Sig. — A  tablespoonful  every  two  hours. 

Or— 

^  Caffein.  eitrat. ,  gr.  xij  ; 

Phenacetin,  gr.  xviij  ; 

Sodii  bromid.,  3j. — M. 
Ft.  in  chart.  Ko.  vi. 
Sig.— One  powder  every  hour. 

Or— 

^   Salol,  3j  ; 

CafFein,  eitrat., 
Phenacetin,  aa  gr.  xviij. — M. 
Ft.  in  chart.  No.  vi. 
Sig. — One  every  two  hours. 

The  Interval. — Careful  search  should  be  made  for  some  ex- 
citing cause,  aud  vs^hen  found,  removed  if  possible.  The  habits 
of  the  patient  must  be  regulated.  Overwork  and  the  use  of 
alcohol,  strong  tea  and  coffee  must  be  interdicted.  Systematic 
exercise  and  frequent  bathing  followed  by  friction  are  valuable 
adjuncts.  The  diet  must  be  adapted  to  the  condition  of  the 
stomach  and  the  needs  of  the  system.  Internally,  arsenic, 
iodide  of  potassium,  bromide  of  potassium,  valerianate  of  zinc, 
and  cannabis  indica  are  the  most  reliable  remedies.  Cannabis 
indica  is  often  very  efficient,  and  a  quarter  to  half  a  grain  of 
the  extract  may  be  given  for  a  prolonged  period.  Little 
recommends  : — 

^  Sodii   arsenat.,  gr.  ij  ; 

Ext.  cannabis  indicse,  gr.  iv ; 

Ext.  belladonuEe,  gr.  viij.— M. 
Ft.  in  pil.    No,  xxiv. 
Sig. — One,  twice  daily. 

HEADACHE. 

(Cephalalgia.) 

Definition. — Pain  in  the  head  generally  resulting  from  a 
disturbance  of  the  cerebral  circulation,  a  perverted  condition 
of  the  blood,  reflex  irritation,  or  pressure  on  the  brain  by  in- 
flammatory exudate,  depressed  bone,  or  a  tumor. 


376  DISEASES   OF  THE   NERVOUS  SYSTEM. 

Organic  Headache. — This  form  is  observed  in  meniDgitis, 
cerebral  tumor,  abscess,  softening,  etc.,  and  may  be  recognized 
by  its  persistence  and  by  the  associated  evidences  of  organic 
cerebral  disease,  such  as  optic  neuritis,  mental  aberration, 
paralysis,  especially  of  the  facial  muscles,  and  vomiting 
arising  independently  of  other  gastric  symptoms. 

Under  this  head  is  included  the  headache  of  syphilis,  which 
may  be  diagnosed  by  the  history  ;  by  the  other  evidences  of 
syphilis;  by  its  frequent  association  with  somnolence  ;  and 
by  the  effect  of  iodide  of  potassium. 

Headache  of  Cerebral  Hypersemia. — Active  cerebral  con- 
gestion usually  results  from  prolonged  mental  work,  fever, 
or  exposure  to  the  sun.  Toxic  and  reflex  headaches  are  often 
directly  due  to  active  cerebral  congestion,  but  these  will  be 
discussed  later. 

Passive  cer^ehral  congestion  may  result  from  obstruction  to 
the  return  of  blood  from  the  brain,  as  by  a  tumor  of  the  neck, 
or  cardiac  disease.  It  is  also  common  in  elderly  people  from 
a  relaxed  condition  of  the  vessels. 

In  cerebral  congestion  the  headache  is  of  a  throbbing  or 
bursting  character ;  the  head  is  hot ;  the  face  flushed ;  the 
eye-ground  injected  ;  and  the  distress  is  increased  by  lowering 
the  head. 

The  exciting  cause  must  be  determined  by  the  history  and 
by  a  careful  examination  of  the  various  organs,  especially  the 
heart. 

Headache  of  Cerebral  Ansemia.— This  is  frequently  de- 
pendent upon  general  anaemia.  It  is  also  common  in  neuras- 
thenia resulting  from  overwork,  prolonged  emotional  excite- 
ment, excesses,  etc.  More  rarely  it  is  dependent  upon  aortic 
stenosis. 

In  cerebral  ansemia  the  pain  is  frequently  vertical ;  it  is  not 
throbbing,  but  it  is  described  as  a  sensation  of  weight  or  gnaw- 
ing ;  the  extremities  are  cold  ;  the  face  and  eye-grounds  are 
pale ;  the  mind  is  depressed ;  fainting  spells  are  often  present ; 
lowering  the  head  and  the  inhalation  of  nitrite  of  amyl  relieve 
the  pain. 

Reflex  Headache. — Headache  is  often  due  to  eye-strain  re- 
sulting from  refraction  errors,  and  in  obstinate  cases  a  careful 


HEADACHE.  377 

examination  of  the  eyes  should  always  be  made.  Headache 
of  this  origin  is  frequently  a  browache,  and  may  be  associated 
with  restlessness,  vomiting,  and  insomnia.  It  is  induced  or 
aggravated  by  prolonged  use  of  the  eyes. 

Ovarian  or  utetine  diseases  often  produce  a  reflex  headache. 
It  is  usually  located  at  the  vertex,  and  is  relieved  by  pressure 
of  the  hand. 

OadriG  irritation  is  responsible  for  many  headaches;  the 
latter  are  invariably  relieved  by  vomiting,  and  are  usually 
associated  with  other  evidences  of  stomachic  disorder. 

Nasal  catarrh  may  induce  persistent  headache,  which  is 
generally  confined  to  the  forehead,  temples,  or  vertex,  and  is 
aggravated  by  exacerbations  of  the  catarrah.  The  pain  is 
often  associated  with  tenderness  of  the  inner  wall  of  the  orbit, 
and  is  increased  by  irritating  the  nasal  mucous  membrane 
with  a  probe. 

Toxaemic  Headache. — A  persistent  headache  often  results 
from  Bright's  disease,  and  is  urcsmic  in  origin.  It  may  be 
recognized  by  the  high  arterial  tension  and  by  the  albumin 
and  casts  in  the  urine.  A  urinary  analysis  should  be  made  in 
all  cases  of  persistent  headache. 

Gout  or  lithcemia  produces  an  intractable  headache  which  is 
associated  with  vertigo,  great  irritability  of  temper,  and  a 
"  brick-dust"  deposit  in  the  urine. 

Chronic  malarial  j^oisoning  may  manifest  itself  in  a  head- 
ache which  is  usually  confined  to  the  supraorbital  region.  It 
is  apt  to  recur  at  regular  intervals,  is  often  associated  with 
tenderness  over  the  supraorbital  nerve,  and  is  only  relieved 
by  large  doses  of  quinine. 

A  headache  of  'rheumatic  origin  sometimes  develops  in  those 
subject  to  rheumatism.  It  is  frequently  excited  by  exposure 
or  a  sudden  change  of  temperature.  It  usually  affects  the 
aponeurosis  of  the  occipito-frontalis  and  temporal  muscles,  is 
increased  by  wrinkling  the  forehead  and  forcibly  moving  the 
jaws,  and  is  associated  with  tenderness  of  the  scalp. 

Alcoholism  is  often  associated  with  headache.  In  acute 
alcoholism,  the  headache  probably  results  from  cerebral  hyper- 
semia ;  in  chronic  alcoholism  it  is  often  due  to  a  low  grade  of 
meningitis. 


378  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Among  other  headaches  of  toxic  origin  may  be  mentioned 
those  due  to  constipation,  lead-poisoning,  diabetes,  infectious 
fevers,  and  absorption  of  foul  gases. 

Hysterical  Headache. — In  hysteria  there  is  often  a  per- 
sistent headache,  which  grows  worse  at  the  menstrual  periods, 
and  which  improves  under  pleasurable  excitement.  It  may  be 
diffuse,  but  frequently  it  is  localized,  and  is  described  as 
resembling  the  effect  which  would  be  produced  by  a  nail  being 
driven  into  the  head ;  hence  it  has  been  termed  clavus. 

Diagnosis. — Headache  must  be  distinguished  from  mi- 
graine. In  the  latter  there  are  usually  prodromal  symptoms, 
disturbances  of  vision,  pupillary  changes,  and  the  pain  is  fre- 
quently confined  to  one  side  of  the  head. 

Headache  in  the  region  of  the  orbit  may  be  mistaken  for 
acute  glaucoma,  but  in  the  latter  condition  the  eye  is  inflamed  ; 
the  cornea  is  hazy ;  the  pupil  is  sluggish ;  vision  is  impaired  ; 
and  on  palpation  the  affected  eyeball  is  found  to  be  harder 
than  its  fellow. 

Treatment. — In  the  interval  between  the  attacks  careful 
search  should  be  made  for  the  cause,  which,  if  possible,  must 
be  removed.  In  the  reflex  headache  of  eye-strain  the  ad- 
justment of  proper  glasses  is  often  all  that  is  required.  In 
gastric  headache,  the  associated  catarrh  of  the  stomach  must  be 
treated  by  alight  diet  and  the  use  of  such  remedies  as  bismuth 
and  nitrate  of  silver.  •  In  the  headache  of  anaemia,  a  nutritious 
diet,  with  iron,  arsenic,  and  other  tonics  will  be  required.  In 
headaches  of  ursemic  origin,  a  milk  diet  with  measures  cal- 
culated to  increase  the  action  of  the  skin,  bowels,  and  kidneys, 
will  often  afford  considerable  relief.  In  malarial  headache 
quinine  in  large  doses  with  arsenic  will  effect  a  cure. 

The  Attack. — In  headache  dependent  upon  gastric  acidity, 
after  unloading  the  stomach  with  a  non-irritating  emetic, 
bromides  with  antacids  will  prove  useful,  thus  : — 

1^  Sodii  bromid.,  gij  ; 

Spt.  ammon.  aroraat.,  fgij  ; 
Aquae  q.  s.  ad  f^iij. — M. 
Sig. — A  tablespoonful  every  hour  or  two. 

In  headache  of  acute  cerebral  congestion  the  feet  should  be 
soaked  for  ten  or  fifteen  minutes  in  very  hot  water ;  an  ice- 


NEUEITIS.  379 

bag  placed  on  the  head  ;  and  some  sedative  like  the  following 
administered  : — 

]^  Phenacetin,  3j  ; 

Sodii  broraid.,  ^ss. — M. 
Ft.  in  chart  No.  xii. 
Sig. — One  powder  every  hour  or  two  until  relieved. 

When  the  attack  is  very  severe,  aconite  (gtt.  j-ij)  may  be 
given  every  hour  or  two. 

In  cerebral  aneemia  good  temporarily  follows  the  use  of 
antipyrin  or  phenacetin,  especially  in  combination  with  caffeine, 
thus : — 

^  Phenacetin,  3j  ; 

Caffein.  citrat.,  gr.  xxiv.— M. 
Ft.  in  chart  No.  xii. 
Sig. — One  as  required. 

In  rheumatic  headache  salol  is  ver}'^  useful ;  it  may  be  com- 
bined with  antipyrin  : — 

^   Salol,  5SS ; 

Antipyrin,  gj. — M. 
Ft.  in  chart  No.  x. 
Sig. — One  every  hour  or  two  until  relieved. 

In  ursemic  headache  the  diet  should  be  restricted  to  milk, 
action  of  the  bowels  secured  by  a  saline  draught,  and  diuresis 
encouraged  by  digitalis,  caffeine,  or  the  vegetable  salts  of  po- 
tassium : — 

^  Potass,  citrat.,  ,^ij  ; 
Spt.  juniperi,  f^vj  ; 
-^ther.  nitros. ,  fgij  ; 
Infus.  scoparii,  ^vj. — M.     (DAY.) 
A  wineglassful,  thrice  daily. 

NEURITIS. 

Definition. — Inflammation  of  nerves. 

Etiology. — (1)  It  may  result  from  traumatism — blows, 
wounds,  or  compression.  (2)  It  may  be  due  to  exposure  to 
cold  and  wet.  (3)  It  may  be  secondary  to  inflammation  of 
adjacent  structures.  (4)  It  may  be  secondary  to  rheumatism, 
gout,  syphilis,  or  one  of  the  infectious  fevers. 


380  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Pathology.- — The  sheath,  interstitial  connective  tissue,  or 
fibres  may  be  independently  affected,  but  as  a  rule,  all  parts  of 
the  nerve  are  involved.  When  the  process  is  acute  the  nerve 
is  red  and  swollen,  and  microscopic  examination  reveals  an 
infiltration  of  leucocytes,  with  more  or  less  granular  degenera- 
tion of  the  fibres. 

In  chronic  neuritis  the  nerve-trunk  is  gray,  shrivelled,  and 
hard,  and  microscopic  examination  shows  an  overgrowth  of 
connective  tissue  and  granular  degeneration  of  fibres. 

Symptoms  of  Acute  Neuritis. — There  are  three  sets  of 
phenomena — sensory,  motor,  and  trophic. 

Setisory  Symptoms.  —  There  is  severe  pain  following  the 
course  of  the  affected  nerve,  which  is  tender  to  the  touch.  The 
pain  is  often  associated  with  various  manifestations  of  parses- 
thesia,  such  as  burning,  numbness,  tingling,  and  the  like.  The 
part  is  at  first  hypersesthetic,  but  later  it  is  more  or  less  anaes- 
thetic. 

Motor  Symptoms. — Muscular  power  is  impaired  ;  there  may 
be  fibrillar  tremors ;  and  the  reflexes  are  diminished  or  lost. 

Trophic  Symptoms. — An  eruption  of  herpes  sometimes  fol- 
lows the  affected  nerves.  The  skin  may  become  glossy  and 
the  nails  lustreless  and  brittle.  In  advanced  cases  there  are 
wasting  of  muscles  and  impaired  electro-contractility.  Occa- 
sionally effusion  into  the  joints  is  observed. 

In  some  cases  there  may  be  febrile  symptoms. 

Chronic  neuritis  is  characterized  by  pain,  ansesthesia,  paresis, 
atrophy  and  contracture  of  the  muscles,  reactions  of  degen- 
eration, "  glossy  skin/'  and  thickening  and  brittleness  of  the 
nails. 

Diagnosis. — Neuritis  may  be  mistaken  for  neuralgia  ;  but 
in  the  latter  the  pain  is  paroxysmal  and  is  unassociated  with 
tenderness  along  the  course  of  the  nerve,  parsesthesia,  anaes- 
thesia, paresis,  and  changes  in  the  electro-contractility. 

Prognosis. — In  acute  cases  the  prognosis  is  guardedly 
favorable ;  the  duration  is  from  a  few  days  to  several  weeks. 
In  chronic  neuritis,  after  the  development  of  marked  trophic 
changes,  the  prognosis  is  grave. 

Treatment. — The  cause  should  be  ascertained  and,  if  pos- 
sible, removed.     In  rheumatism,  alkalies  and  salicylates  are 


MULTIPLE   NEUEITIS.  381 

indicated.  In  syphilis,  iodide  of  potassium  should  be  admin- 
istered in  large  doses.  The  part  should  be  put  at  rest. 
For  the  pain,  sedative  lotions  (lead-water  and  laudanum), 
warm  fomentations,  or  small  blisters  may  be  applied  to  the 
affected  parts,  and  morphine  administered  hypodermically. 
When  morphine  is  contraindicated,  salicylate  of  sodium  or 
phenacetin  may  be  employed  in  its  stead.  After  the  sub- 
sidence of  acute  symptoms,  iodide  of  potassium  may  be  given 
for  its  absorbent  effect  and  small  blisters  applied  locally. 
Restoration  of  power  will  be  assisted  by  massage  and  elec- 
tricity, and  by  the  administration  of  stryclmine,  internally  or 
hypodermically. 

MlILTIPluE  NEURITIS. 

Definition. — Inflammation  of  several  nerve-trunks,  re- 
sulting from  a  general  cause,  and  characterized  by  pain, 
parsesthesia,  anaesthesia,  paresis,  and  muscular  atrophy. 

Etiology. — Alcoholism,  syphilis,  rheumatism,  the  infec- 
tious fevers,  exposure  to  cold  and  wet,  and  mineral  poisoning 
are  common  causes.  In  the  Orient,  multiple  neuritis  occurs 
as  an  endemic  disease  (Kakke  or  Beri-beri),  which  is  probably 
microbic  in  origin. 

Symptoms. — The  acute  form  is  characterized  by  a  chill  fol- 
lowed by  moderate  fever  (102°-103°),  headache,  pain  in  the 
back,  malaise,  coated  tongue,  loss  of  appetite,  constipation, 
febrile  urine,  and  the  following  local  phenomena  :  Pain,  numb- 
ness, and  tingling  in  the  affected  limbs;  loss  of  power,  espe- 
cially in  the  legs  and  extensor  muscles;  abolition  of  the 
reflexes;  atrophy  of  the  muscles;  more  or  less  anaesthesia; 
and  tenderness  over  the  nerve-trunks. 

Chronic  Form. — Febrile  symptoms  are  absent  and  the  dis- 
ease is  manifested  by  pains  in  the  limbs,  hypersesthesia,  paraes- 
thesia,  irregular  areas  of  anaesthesia,  loss  of  power,  abolition 
of  the  deep  reflexes,  tenderness  over  the  nerve-trunks,  wasting 
of  the  muscles,  impaired  electrical  contractility,  and  cedema  of 
the  hands  and  feet. 

Complications. — Delirium,  delusions,  and  hallucinations 
are  not  uncommon,  especially  in  the  alcoholic  variety.  The 
disease  is  sometimes  associated  with  locomotor  ataxia. 


382  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Diagnosis.  Locomotor  Ataxia. — The  absence  of  the  light- 
ning-pains, girdle  sensation,  Argyll-Robertson  pupil,  and  the 
presence  of  paralysis,  wasting,  and  neural  tenderness  will  serve 
to  distinguish  multiple  neuritis  from  locomotor  ataxia. 

Prognosis. — Guardedly  favorable.  Acute  neuritis  some- 
times proves  fatal  from  involvement  of  the  respiratory  mus- 
cles. In  chronic  cases  of  long  duration  the  outlook  is  not 
hopeful. 

Treatment. — Acute  cases  should  be  kept  at  absolute  rest. 
For  the  relief  of  pain  hot  fomentations,  lead-water  and  lauda- 
num, and  rubefacient  liniments  may  be  applied  to  the  affected 
limbs;  and  morphine,  antipyrin,  phenacetin,  or  salicylic  acid 
administered  internally.  After  acute  symptoms  have  sub- 
sided, massage,  electricity,  and  Swedish  movements  should  be 
employed  to  secure  a  return  of  power.  An  ointment  of 
mercury  and  belladonna  may  be  used  for  its  absorbent  and 
anodyne  effect.  Strychnine  hypodermically  is  an  invaluable 
muscular  tonic.  Rigidity  is  best  relieved  by  manipulation 
and  the  frequent  use  of  warm  baths.  In  syphilitic  cases  em- 
ploy mercurial  inunctions  and  iodide  of  potassium. 

SCIATICA. 

Definition. — Pain  along  the  sciatic  nerve,  usually  resulting 
from  neuritis. 

Etiology. — Male  sex,  middle  life,  gout,  rheumatism,  and 
syphilis  are  predisposing  causes.  Exposure  to  cold  and  wet 
is  the  common  exciting  cause.  Very  rarely  sciatica  is  a  sec- 
ondary condition  resulting  from  the  presence  of  an  intra-pelvic 
growth  or  from  caries  of  the  bone  in  joint  disease. 

Symptoms. — The  disease  may  begin  abruptly  or  gradually, 
and  is  characterized  by  a  sharp  shooting  pain  running  down 
the  back  of  the  thigh.  Movement  of  the  limb  intensifies  the 
suffering.  The  pain  may  be  uniformly  distributed  along  the 
course  of  the  nerve,  but  not  infrequently  there  are  certain 
spots  where  it  is  more  intense.  Subjective  sensations,  such 
as  tingling  and  numbness,  are  often  noted.  The  nerve  may 
be  extremely  sensitive  to  touch.  The  symptoms  grow  worse 
at  night  and  on  the  approach  of  stormy  weather.     The  dura- 


FACIAL  PARALYSIS.  383 

tion  of  the  attack  varies  from  a  few  days  to  several  months. 
In  long-standing  cases  the  muscles  become  atrophied  and  rigid. 

Diagnosis.  Coxalgia. — In  this  affection  the  pain  is  most 
marked  in  the  hip-  and  knee-joints ;  pressure  over  the  tro- 
chanter elicits  pain  ;  and  the  nerve  is  not  tender  to  the  touch. 

Prognosis. — Recovery  follows  in  the  majority  of  cases 
when  treatment  is  instituted  early  and  is  persistently  carried 
out.  In  some  cases  relapses  occur  frequently,  and  finally  the 
pain  becomes  more  or  less  continuous. 

Treatment. — In  the  acute  stage  rest  is  essential.  Hot 
fomentations  or  linear  blisters  may  be  applied  along  the 
course  of  the  nerve.  Deep  injections  of  morphine,  anti pyrin, 
or  cocaine  may  be  required  to  relieve  the  pain.  In  rheumatic 
cases  full  doses  of  the  salicylate  of  sodium  are  very  useful. 
In  chronic  cases  prolonged  rest  is  desirable.  Counter-irritation 
should  be  made  by  frequent  small  blisters,  by  the  actual  cautery, 
or  by  acupuncture.  Deep  injections  along  the  course  of  the 
nerve  give  much  relief,  and  one  of  the  following  remedies  may 
be  so  employed:  morphine  and  atropine,  cocaine,  antipyriu, 
or  plain  water.  Electricity  sometimes  does  good.  Internally 
iodide  of  potassium  in  small  doses  is  useful ;  in  syphilitic 
cases  it  should  be  given  in  large  doses.  The  following  com- 
bination is  also  efficient : — 

^  Tinct.  acouiti  rad., 
Tinct.  colchici  sem., 
Tinct.  belladonnjB, 

Tinct.  cimicifugse,  aa  fgij. — M.     (Metcalf.) 
Sig. — Twelve  drops  every  four  to  eight  hours. 

FACIAL  PARALYSIS. 

(BeU's  Palsy.) 

Etiology. — Paralysis  of  one  side  of  the  face  may  result : 

(1)  From  a  tumor,  clot  or  abscess  involving  the  facial  centre 
on  the  cortex  of  the  brain  or  the  nucleus  of  the  facial  nerve ; 

(2)  from  the  pressure  of  inflammatory  exudate  on  the  nerve- 
trunk  between  the  brain  and  the  skull ;  (3)  from  paralysis  of 
the  nerve  within  the  petrous  portion  of  the  temporal  bone, 
excited  by  a  fracture,  or  by  an  extension  of  inflammation  of 


384  DISEASES   OF   THE   NERVOUS   SYSTEM. 

the  middle  ear ;  (4)  from  inflammation  of  the  peripheral  fila- 
ments, excited  by  exposure,  injury,  rheumatism,  or  one  of  the 
infectious  fevers. 

SvMPTOMS.-^The  side  affected  is  expressionless  ;  the  natural 
lines  are  obliterated  ;  the  angle  of  the  mouth  droops  ;  the  eye 
cannot  be  closed ;  tears  flow  over  the  cheek  ;  and  speech  is 
affected  from  an  inability  to  pronounce  the  labials.  When 
the  patient  attempts  to  laugh  or  whistle,  the  absence  of  move- 
ment on  the  affected  side  becomes  still  more  conspicuous.  In 
peripheral  neuritis  the  reflexes  are  abolished  ;  and  when  the 
nerve  is  involved  in  the  temporal  bone  there  may  be  a  loss  of 
taste  in  the  anterior  part  of  the  tongue. 

Diagnosis. — When  the  lesion  is  in  the  brain  the  paralysis 
is  rarely  complete,  the  upper  part  of  the  face  usually  escaping; 
neighboring  cranial  nerves  are  frequently  affected;  and  other 
evidences  of  organic  brain  disease  are  generally  present. 

When  the  nerve  is  involved  within  the  Fallopian  canal 
there  is  often  a  loss  of  taste  in  the  anterior  part  of  the  tongue, 
and  some  disturbance  of  hearing — deafness  or  perhaps  hyper- 
sensitiveness  to  sound. 

In  peripheral  neuritis  the  history,  the  completeness  of  the 
paralysis,  and  the  absence  of  reflexes  will  assist  in  the  recog- 
nition of  the  lesion. 

Prognosis. — The  prognosis  will  vary  with  the  cause.  It 
should  be  guardedly  favorable  when  the  paralysis  is  due  to 
peripheral  neuritis. 

Treatment. — The  cause  should  be  ascertained,  and  if  pos- 
sible, removed.  In  paralysis  of  centric  origin  little  can  be 
done,  except  in  syphilitic  cases.  In  middle-ear  disease  reme- 
dies should  be  directed  to  that  organ.  When  paralysis  results 
from  inflammation  of  the  peripheral  filaments  of  the  facial 
nerve,  blisters  should  be  applied  near  the  stylo-mastoid  fora- 
men, and  as  it  often  appears  to  be  an  expression  of  rheumatism, 
salicylates  may  be  given  internally.  Later,  a  course  of  iodide 
of  potassium  will  be  useful,  and  restoration  of  power  may  be 
materially  assisted  by  massage,  electricity,  and  local  injections 
of  strychnine. 


EPILEPSY.  ;385 

EPILEPSY. 

(Idiopathic  Epilepsy,  Falling  Sickness.) 

Definition. — A  chronic  disease  of  the  nervous  system, 
characterized  by  paroxysms  of  unconsciousness  which  are 
usually  associated  with  general  convulsions. 

Etiology. — Heredity  predisposes,  and  the  ancestral  disease 
may  not  have  been  epilepsy  but  insanity,  hysteria,  or  another 
neurosis.  It  generally  begins  before  puberty,  and  very  rarely 
after  the  twenty-fifth  year.  All  causes  which  impair  the 
health  and  exhaust  the  nervous  system  exert  a  predisposing 
influence.  The  reflex  convulsions  of  children  resulting  from 
gastric  irritation,  worms,  etc.,  if  long  continued  may  induce 
chronic  epilepsy.  In  these  cases,  although  the  exciting  cause 
has  been  removed,  the  habit  of  spontaneous  motor  discharge, 
through  constant  repetition,  is  established,  and  may  continue 
through  life.  In  those  subject  to  convulsions,  overwork,  gas- 
tric irritation,  or  excitement  may  precipitate  an  attack. 

Pathology. — No  demonstrable  causal  lesions  are  detected. 
The  disease  apparently  depends  upon  an  instability  of  the  motor 
centres,  so  that  from  trivial  exciting  causes  violent  discharges 
occur  from  time  to  time. 

Symptoms.  Grand  Mai. — The  seizure  is  often  preceded  by 
a  peculiar  sensation  termed  an  aiira,  beginning  in  a  finger  or 
toe  and  rising  until  it  involves  the  head,  when  the  patient  gives 
a  shrill  scream  and  falls  to  the  floor  unconscious.  At  first  the 
face  is  pale,  the  pupils  contracted,  and  tlie  body  thrown  into  a 
tonic  spasm  in  which  the  head  is  retracted  and  rotated,  the 
limbs  forcibly  extended,  and  the  thumbs  turned  into  the  palms 
and  firmly  clenched  by  the  flexed  fingers.  In  a  few  seconds 
the  tonic  spasm  relaxes,  the  movements  become  clonic  or 
intermittent,  the  pupils  dilated,  the  face  cyanosed,  and  from 
the  violent  contraction  of  the  masseters  frothy  saliva,  often 
blood-streaked,  pours  from  the  mouth.  The  clonic  spasms 
continue  for  a  minute  or  two,  and  are  generally  followed  by  a 
period  of  coma  lasting  from  a  few  minutes  to  several  hours. 
Sometimes  the  patient  returns  at  once  to  consciousness,  and 
complains  simply  of  weakness,  muscular  soreness,  and  mental 
confusion.  More  rarely  the  convulsion  is  followed  by  an  out- 
25 


386  DISEASES   OF   THE  NERVOUS  SYSTEM. 

break  of  mania,  or  of  epileptic  automatism,  a  condition  in 
which  the  patient  performs  some  incongruous  act. 

Petit  Mai. — In  this  type  the  seizure  consists  of  momentary 
unconsciousness,  with  pallor,  and  perhaps  twitching  of  the 
muscle.  The  patient  suddenly  stops  in  the  midst  of  his  work 
or  conversation,  remains  quiet  for  a  few  seconds,  and  then  con- 
tinues where  he  left  oif,  perhaps  unconscious  of  the  interrup- 
tion. Petit  mal  may  be  a  forerunner  oi grand  mal  or  may  alter- 
nate with  it. 

Between  these  two  extremes,  the  seizures  manifest  all  grades 
of  severity.  The  frequency  of  the  paroxysms  varies  consider- 
ably ;  they  may  occur  as  seldom  as  once  a  year,  or  as  often  as 
ten  or  twelve  times  a  day.  A  marked  periodicity  in  their  re- 
currence is  often  observed. 

The  term  "  status  epilepticus"  is  applied  to  a  series  of  con- 
vulsions which  follow  each  other  in  rapid  succession,  and 
which  are  associated  with  high  fever. 

The  epileptic  may  manifest  no  other  symptoms  beyond  the 
convulsions,  but  when  the  latter  are  very  frequent  the  health 
fails  and  the  mental  power  deteriorates. 

Diagnosis. — The  convulsions  of  idiopathic  epilepsy  must 
be  distinguished  from  those  due  to  organic  brain  disease  (organic 
epilepsy).  The  latter  affection  rarely  develops  before  twenty- 
five  ;  the  aura  may  be  connected  with  the  special  senses,  which 
is  uncommon  in  idiopathic  epilepsy ;  the  convulsion  is  often 
confined  to  one  member  or  to  one  side  of  the  body,  and  may 
not  be  associated  with  unconsciousness  (Jacksonian  epilepsy) ; 
the  convulsion  may  begin  in  one  member  and  then  become 
generalized ;  and  finally,  in  a  large  proportion  of  the  cases  of 
organic  epilepsy,  there  will  be  a  history  or  concomitant  symp- 
toms of  syphilis,  or  the  evidence  of  cerebral  injury. 

Uroemia. — Ursemic  convulsions  may  be  recognized  by  the 
history  and  the  results  of  the  urinary  analysis. 

Prognosis. — Generally  unfavorable.  Arrest  of  the  dis- 
ease is  rare,  but  amelioration  is  often  secured  by  treatment. 

Treatment.  Preventive. — Careful  search  should  be  made 
for  the  cause  which  excites  the  paroxysms ;  this  will  often  be 
found  in  some  disturbance  of  the  gastro-intestinal  tract.  The 
diet  should  be  light,  and  as  a  rule,  largely  vegetable.     Con- 


APHASIA.  387 

stipation  must  be  relieved  by  diet,  exercise,  or  the  use  of  mild 
laxatives.  Undue  mental  and  physical  excitement  should  be 
avoided.  Systematic  exercise  and  frequent  bathing  followed 
by  friction  of  the  skin  lessen  the  sensitiveness  of  the  nervous 
system.  The  most  reliable  drugs  are  the  bromides ;  one  or 
two  drachms  of  a  combination  of  the  bromides  of  sodium, 
potassium,  and  ammonium  may  be  given  daily.  Strontium  bro- 
mide is  often  efficacious,  and  it  is  less  depressing  than  the  other 
bromides.  The  tendency  to  acne  may  be  considerably  lessened 
by  the  addition  of  a  drop  or  two  of  Fowler's  solution  with  each 
dose.  A  small  amount  of  antipyrin  often  lessens  the  amount 
of  the  bromide  required  to  check  the  convulsions. 

^  Ammon.  bromid.,  ^vj  ; 
Antipyrin,  3j  ; 
Liq.  potass,  arsenitis,  f^j  ; 
Aq.  men  thee  pip.,  q.  s.  ad  f^vj. — M.     (Wood.) 
Sig. — Tablespoonful  in  water  night  and  morning. 

When  the  bromides  fail,  one  of  the  following  remedies  may 
be  employed :  oxide  of  zinc  (gr.  vj-xv  a  day),  picrotoxin  (gr. 
j^-Q  thrice  daily),  sulphonal,  borax,  or  belladonna. 

When  an  au)-a  gives  warning  of  a  seizure,  the  inhalation  of 
nitrite  of  amyl  may  abort  it. 

Surgical  interference  is  indicated  in  Jacksonian  epilepsy, 
and  in  those  cases  in  which  the  convulsion  begins  in  one  mem- 
ber and  subsequently  becomes  generalized. 

The  Attack. — As  the  seizure  is  short,  special  treatment  is 
rarely  required.  Injury  of  the  tongue  may  be  prevented  by 
placing  a  piece  of  cork  between  the  teeth.  In  the  status  epilepti- 
cus  chloroform  or  nitrite  of  amyl  may  be  administered  by  inhala- 
tion, and  hyoscine  (gr.  yww)  ^^  morphine  given  hypodermically. 

APHASIA. 

(Aphemia.) 

DEFiNiTioisr. — An  inability  to  express  thoughts  in  words  or 
to  interpret  perceptions. 

Motor  or  Ataxic  Aphasia — In  this  form  the  patient  has 
lost  the  mechanism  whereby  thoughts  are  converted  into  words, 
although  he  may  be  able  to  repeat  the  words  after  anotherj  to 


388  DISEASES  OP  THE   NERVOUS  SYSTEM. 

write  them,  or  to  read  them.  The  lesion  producing  this  form 
of  aphasia  is  located  in  the  left  third  frontal  convolution. 

Agraphia  is  an  inability  to  express  thought  in  written  lan- 
guage.    It  is  usually  associated  with  motor  aphasia. 

Alexia  is  an  inability  to  express  written  language  in  words. 
It  is  also  commonly  associated  with  motor  aphasia. 

Sensory  Aphasia. — This  is  an  inability  to  interpret  percep- 
tions.    There  are  the  following  varieties  : — 

Word-blindness. — This  is  an  inability  to  interpret  written 
language.  The  lesion  is  usually  in  the  supramarginal  and 
angular  gyri  of  the  left  side. 

Word-deafness. — An  inability  to  interpret  spoken  language. 
The  sound  of  the  word  is  not  recognized  and  cannot  be  re- 
called. The  lesion  is  in  the  posterior  part  of  the  first  and 
second  temporal  convolutions. 

Mlnd-hlindness  {Apraxia,  Visual  Amnesia). — An  inability  to 
recognize  the  use  or  import  of  an  object.  Seeing  an  object 
awakens  no  intelligent  idea  of  its  use.  The  lesion  is 
probably  in  the  supramarginal  and  angular  gyri  of  the  left 
side. 

Mind-deafness  {Auditory  Amnesia). — An  inability  to  inter- 
pret sounds.  The  patient  hears  the  words,  can  recognize 
and  repeat  them,  but  cannot  interpret  them. 

Paraphasia. — An  inability  to  use  the  right  word  in  continued 
speech.  He  can  interpret  and  use  words,  but  is  constantly 
misplacing  them. 

Pathology. — The  lesions  which  produce  aphasia  are 
manifold ;  the  most  important  are  :  Tumor,  gumma,  abscess, 
depressed  fracture,  embolism,  thrombus,  or  softening  in  the 
localities  which  correspond  to  the  various  forms  of  aphasia. 
In  right-handed  subjects  the  lesion  is  on  the  left  side  of  the 
brain  ;  in  the  left-handed  it  may,  however,  be  on  the  right  side. 
Aphasia  is  not  always  due  to  organic  disease ;  it  may  be  noted 
in  congestion  of  the  brain,  in  sudden  fright,  in  the  convales- 
cence of  fevers,  in  migraine,  after  epileptic  seizures,  and  in 
hysteria. 

Diagnosis. — ^Aphasia  must  be  distinguished  from  aphonia. 
The  latter  condition  is  an  inability  to  utter  sounds,  a  power 
not  lost  in  aphasia ;  moreover,  aphonia  is  generally  dependent 


VERTIGO.  389 

upon  some  abnormality  of  the  larynx  or  of  the  nerves  leading 
thereto. 

Prognosis. — This  depends  entirely  on  the  cause.  After 
apoplexy  the  prognosis  should  be  guarded.  In  cerebral  soft- 
ening it  is  absolutely  unfavorable.  When  aphasia  develops 
in  the  young  the  outlook  is  much  more  hopeful. 

Treatment. — The  causal  condition  will  require  attention. 
The  patient  may  be  instructed  to  speak  and  to  interpret  after 
the  manner  employed  in  teaching  the  young. 

VERTIGO. 

(Dizziness,  Giddiness,  SAvimming  in  the  Head.) 

Definition. — A  sense  of  unstable  equilibrium  in  which 
the  patient  himself  or  surrounding  objects  appear  to  be  in  a 
state  of  rapid  oscillation  or  rotation.  It  is  a  symptom  of 
many  conditions. 

Etiology. — "Vertigo  may  result  from  : — 

1.  Cerebral  ansemia  or  congestion.  The  dizziness  preceding 
a  fainting  fit  is  an  illustration  of  the  former,  and  that  follow"- 
ing  exposure  to  the  rays  of  the  sun  is  an  illustration  of  the 
latter.  Vertigo  is  often  a  pronounced  symptom  of  chronic 
cerebral  congestion  and  ausemia.  The  vertigo  of  chronic  heart 
disease  and  of  neurasthenia  is  included  under  this  head. 

2.  Reflex  irritation.  The  most  common  example  of  this 
form  is  the  vertigo  dependent  upon  gastric  disturbances.  It 
is  also  noted  in  eye-strain,  uterine  disease,  constipation,  and 
disease  of  the  internal  ear.  The  last  is  termed  labyrivithine 
vertigo,  or  Meniere's  disease,  and  has  been  described  elsewhere. 

3.  Organic  disease  of  the  brain  and  cord.  Cerebral  tumor, 
meningitis,  and  softening  are  frequently  associated  with  vertigo. 
It  is  often  quite  marked  in  cerebellar  disease.  It  may  be  a 
pronounced  symptom  in  disseminated  sclerosis  and  locomotor 
ataxia. 

4.  Toxic  substances  in  the  blood.  The  vertigo  observed  in 
lithsemia,  uraemia,  and  diabetes  is  included  under  this  head. 
When  taken  in  large  doses,  certain  drugs,  as  alcohol,  bella- 
donna, cannabis  indica,  lobelia,  and  conium,  may  produce  the 


390  DISEASES   or   THE   NEEVOUS  SYSTEM. 

symptoms.     It  is  often  a  marked  symptom  of  chronic  lead- 
poisoning. 

5.  Epilepsy.  Vertigo  may  precede,  follow,  or  take  the 
place  of  an  epileptic  seizure. 

6.  Hysteria.  Occasionally  marked  vertiginous  attacks  are 
connected  with  hysteria. 

7.  Unknown  causes.  The  term  essential  vertigo  has  been 
applied  to  those  cases  in  which,  after  the  most  exhaustive 
study,  no  adequate  cause  can  be  ascertained.  There  is  some- 
times an  hereditary  tendency  to  this  form  of  vertigo. 

Diagnosis. — Vertigo  must  be  distinguished  from  j^cpit  mal, 
or  minor  epilepsy.  The  history,  the  presence  of  a  definite  cause, 
and  the  absence  of  unconsciousness  and  of  convulsive  move- 
ments will  serve  to  separate  vertigo  from  epilepsy. 

The  determination  of  the  cause  of  the  vertigo  must  be 
based  upon  the  history,  the  age  at  which  it  develops,  and  a 
critical  examination  of  the  various  organs. 

Prognosis. — This  will  depend  entirely  on  the  cause  ;  when 
the  latter  can  be  removed,  the  prognosis  is  favorable. 

Treatment. — This  must  be  directed  to  the  causal  condition. 

MENIERE'S  DISEASE. 

(Labyrinthine  Vertigo,   Aural  Vertigo.) 

Definition.  —  Paroxysmal  vertigo,  probably  depending 
upon  disease  of  the  internal  ear. 

Etiology  and  Pathology.  —  The  exact  cause  of 
Meniere's  disease  is  still  undetermined.  In  some  cases,  how- 
ever, inflammatory  changes  hav^e  been  observed  in  the  semi- 
circular canals.  It  is  probable  that  mild  forms  of  the  disease 
can  be  indirectly  induced  by  lesions  of  the  middle  ear. 

Symptoms.  —  Frequently  prodromes  precede  the  attack, 
such  as  deafness  or  earache.  These,  however,  may  be  absent, 
and  the  attacks  ushered  in  with  extreme  vertigo  and  tinnitus 
aurium.  The  latter  is  often  compared  to  the  escape  of  steam, 
the  buzz  of  an  insect,  or  the  discharge  of  a  cannon.  The  patient 
feels  as  if  he  or  surrounding  objects  were  being  whirled  vio- 
lently around,  and  in  severe  cases  the  face  is  pale  and  anxious ; 


HYSTEEIA.  391 

the  surface  is  clammy  ;  there  are  nausea  and  vomiting ;  and  the 
patient  falls  unconscious. 

As  a  rule,  there  is  deafness  in  one  ear  at  least,  but  ex- 
ceptionally, hearing  may  be  quite  normal.  At  first  the 
paroxysms  may  occur  at  long  intervals,  but  as  the  disease 
advances  they  become  more  frequent  and  the  tinnitus  and 
deafness  become  more  marked. 

Diagnosis. — The  paroxysmal  vertigo,  deafness,  and  tinnitus 
aurium  are  the  diagnostic  features. 

Peognosis. — The  prognosis  should  always  be  guarded. 
Some  cases  recover  entirely,  but  in  the  majority  the  vertigi- 
nous attacks  continue  until  the  deafness  in  the  affected  ear 
becomes  complete. 

Treatment. — The  middle  ear  should  be  carefully  ex- 
amined, and  any  existing  disease  treated.  Severe  counter- 
irritation  by  blisters,  or  the  actual  cautery  applied  behind  the 
ear,  may  be  of  some  service.  Bromide  of  potassium  or  large 
doses  of  hydrobromic  acid  may  give  temporary  relief.  Charcot 
recommends  quinine  in  sufficient  doses  to  cause  cinchonism. 

HYSTERIA. 

Definition.  —  Hysteria  is  a  functional  disease  of  the 
nervous  system,  manifested  by  symptoms  of  the  most  varied 
character,  which  apparently  result  from  a  loss  of  control  over 
the  production  of  nerve-power. 

Etiology. — Females  are  especially  predisposed,  although 
it  occasionally  develops  in  males.  It  is  most  common  in  early 
adult  life  and  at  the  menopause.  The  nervous  temperament 
and  such  ancestral  diseases  as  epilepsy,  insanity,  etc.,  favor  its 
development. 

Prolonged  emotional  excitement,  such  as  worriment,  anxiety, 
grief,  and  all  causes  which  lower  the  vitality  serve  to  excite 
it  in  susceptible  individuals. 

Pathology. — No  causal  lesions  can  be  detected  after 
death. 

Symptoms. — The  various  manifestations  may  be  described 
under  three  heads :  (1)  Motor,  (2)  sensory,  and  (3)  psychical. 

Motor  Phenomena. — Paralysis  not  infrequently  results  from 


392  DISEASES   OF   THE   NERVOUS   SYSTEM. 

hysteria ;  it  may  take  the  form  of  a  hemiplegia,  paraplegia,  or 
monoplegia,  although  the  first  is  by  far  the  most  common. 
The  paralysis  is  generally  paroxysmal,  and  is  frequently  asso- 
ciated with  contractures  and  anaesthesia.  The  affected  muscles 
do  not  waste. 

Local  paralysis  is  also  common ;  thus  there  may  be  aphonia 
from  paralysis  of  the  vocal  cords ;  dysphagia,  from  paralysis 
of  the  oesophagus ;  and  incontinence  of  urine,  from  paralysis 
of  the  bladder. 

Convulsive  seizures  are  common  manifestations  of  hysteria, 
and  may  closely  simulate  the  paroxysms  of  true  epilepsy ;  but 
there  is  no  aura;  the  patient  usually  falls  in  a  comfortable 
place ;  consciousness  is  only  apparently  lost,  for  after  the  seiz- 
ure she  remembers  all  that  has  transpired  ;  the  tongue  is  rarely 
bitten  ;  the  eyes  are  partially  closed ;  the  face  is  expressive  of 
some  emotion  ;  screaming  or  sobbing  is  of  frequent  occurrence ; 
the  movements  are  apt  to  be  tonic,  so  that  the  patient  assumes 
the  position  of  opisthotonos,  or  if  clonic,  they  are  apt  to  be 
violent  and  purposive ;  the  seizures  are  of  long  duration,  and 
may  be  continued  for  several  hours  or  days,  and  firm  pressure 
over  the  ovaries  may  exaggerate  or  re-excite  them. 

The  spasms  may  be  local ;  thus  there  may  be  retention  of 
urine,  from  spasm  of  the  bladder ;  asthma,  fi'om  spasm  of  the 
bronchi ;  hiccough,  from  spasm  of  the  diaphragm ;  persistent 
vomiting,  from  spasm  of  the  stomach  ;  dysphagia,  from  spasm 
of  the  oesophagus ;  and  a  "  phantom  tumor,"  from  spasm  of 
abdominal  muscles  associated  with  flatulent  distention  of  the 
intestines. 

Among  other  motor  phenomena  may  be  mentioned  obsti- 
nate tremors,  choreiform  movements,  and  contractures  of  cer- 
tain groups  of  muscles. 

Sensory  Phenomena. — There  may  be  a  complete  loss  of  sen- 
sation in  certain  parts,  as  one  side  of  the  body.  Anaesthesia 
without  other  nervous  phenomena  is  usually  hysterical.  In 
some  cases  tactile  sensation  is  preserv^ed  and  there  is  a  loss 
only  of  thermic  or  painful  sensations.  The  anaesthetic  part  is 
often  unusually  pale,  and  when  pricked  with  a  needle  fails  to 
bleed  (ischaemia). 

The  special  senses  may  be  involved  ;  thus  there  may  be  con- 


HYSTEItlA.  393 

traction  of  the  field  of  vision,  complete  blindness,  loss  of  smell, 
loss  of  taste,  or  loss  of  hearing.  These  special-sense  palsies 
are  usually  transient,  and  often  alternate  with  one  another. 

Instead  of  aneesthesia,  there  may  be  hypersesthesia  or  pain. 
Severe  pain  in  the  stomach  may  simulate  gastralgia.  An  ex- 
quisitely painful  and  tender  condition  of  the  abdomen  may 
be  mistaken  for  peritonitis.  A  localized  pain  in  the  head, 
described  as  resembling  the  eflPect  of  a  nail  being  driven  into  it, 
is  termed  hysterical  clavus.  The  joints  sometimes  become 
swollen  and  very  tender,  resembling  arthritis  (nein'omimesis). 

Intense  pain  over  the  heart  may  simulate  angina  pectoris. 
The  spine  is  often  the  seat  of  hypersesthesia,  especially  in  spots, 
and  this  spinal  irritation  is  often  associated  with  pain  in  parts 
corresponding  to  the  distribution  of  nerves  M'hich  have  their 
origin  in  the  hypersesthetic  area. 

A  very  common  abnormal  sensation  is  the  globus  hystericus, 
i.  e.,  a  feeling  as  of  a  ball  rising  in  the  throat  and  impeding 
respiration. 

Psychical  Phenomena.— Yreqiientij  the  only  conspicuous 
mental  phenomenon  is  the  great  lack  of  will-power ;  but  gen- 
erally the  patients  are  more  or  less  excitable,  highly  mercurial, 
and  easily  moved  to  laughter  or  tears.  They  frequently  mani- 
fest a  great  fondness  for  sympathy,  and  this,  in  connection  with 
their  weak  will-power  and  lowered  moral  tone,  often  leads  them 
to  feign  symptoms  which  they  really  do  not  have.  Among 
the  more  serious  mental  manifestations  may  be  mentioned 
insanity,  ecsta.sy,  catalepsy,  and  trance. 

Diagnosis. — The  recognition  of  hysteria  is  often  attended 
with  great  difficulty,  especially  as  it  is  frequently  associated  with 
symptoms  which  really  have  an  organic  basis.  In  making  a 
diagnosis,  the  history,  sex,  and  temperament  must  be  carefully 
considered.  The  manifestations  usually  develop  abruptly ; 
are  generally  paroxysmal ;  appear  without  obvious  caus(! ; 
often  subside  spontaneously  under  some  emotional  excitement ; 
rarely  lead  to  any  impairment  of  the  health  ;  and  are  usually 
associated  with  a  history  of  other  hy.sterical  phenomena. 

Prognosis. — As  regards  life  the  prognosis  is  good.  In 
rare  instances  death  has  followed  exhaustion  induced  by  re- 
peated   convulsions   or   prolonged   fasting.     While    hysteria 


394  DISEASES  OF  THE  NERVOUS   SYSTEM. 

usually  ends-  in  recovery,  the  duration  of  the  illness  is  a  mat- 
ter of  great  uncertainty. 

A  speedy  recovery  is  to  be  expected  in  those  cases  where 
the  hysterical  phenomena  are  connected  with  some  obvious 
cause  which  can  be  removed. 

Treatment. — Careful  search  should  be  made  for  some 
exciting  cause,  which,  if  found,  should  be  removed  as  far  as 
possible.  The  physical  condition  is  generally  reduced,  and 
careful  study  must  be  given  to  the  diet,  exercise,  amusement, 
clothing,  etc.,  with  the  view  of  improving  it.  Tonics  like 
iron,  arsenic,  strychnine,  hypophosphites,  cod-liver  oil,  and 
malt  are  often  indicated,  and  they  may  be  advantageously 
combined  with  such  nerve  sedatives  as  valerian,  asafoetida,  sura- 
bul,  and  the  like ;  in  the  milder  manifestations,  the  following 
pill  may  prove  useful : — 

R     Acid,  arsenosi,  gr.  i  ; 

Ferri  sulph.  ex., 

Ext.  sumbul,  aa  gr.  xx  ; 

Asafoetidae,  gr.  xl. — M.     (Goodell.) 
Ft.  in  pil.  Ko.  XX. 
Sig. — One  after  each  meal. 

Or— 

^  Quinin.  valerianat., 

Zinci  valerianat., 

Ferri  valerianat.,  aa  gr.  xxiv. — M. 
Ft.  in  pil.  1^0.  xxiv. 
Sig. — One,  thrice  daily. 

The  more  thoroughly  the  physician  is  able  to  inspire  con- 
fidence and  to  control  his  patient,  the  more  likely  is  he  to 
effect  a  cure.  Firmness  tempered  with  kindliness  and  en- 
couragement is  essential  to  success. 

While  hypnotism  appears  to  have  been  somewhat  useful  in 
France,  in  this  country,  although  employed  but  to  a  limited 
extent,  it  has  not  given  encouraging  results,  and  moreover,  in 
the  event  of  failure,  seems  capable  of  aggravating  the  hysteri- 
cal condition. 

In  long-continued  convulsive  seizures,  cold  water  may  be 
dashed  on  the  face  and  chest,  or  hyoscine  administered 
hypodermically.  In  obstinate  cases  an  aneesthetic  should  be 
employed.      In  the  various  form  of  paralysis  electricity  is 


NEURASTHENIA.  395 

often  useful.  In  some  cases  static  electricity,  no  doubt  from 
the  profound  mental  effect  which  it  has  induced,  has  given 
excellent  results. 

In  aggravated  cases  the  "  rest-cure"  introduced  by  S.  Weir 
Mitchell  is  often  applicable.  It  consists  in  isolation  from 
sympathizing  friends  and  relatives;  abuudant  feeding,  espe- 
cially with  milk ;  and  complete  rest  of  body  and  mind  witl^ 
passive  exercise  obtained  by  massage  and  electricity. 

IVEURASTHENIA. 

(Nervous  Prostration.) 

Definition. — A  term  applied  to  a  group  of  symptoms 
apparently  resulting  from  exhaustion  of  the  nerve-centres. 

Etiology. — A  neuropathic  tendency,  prolonged  mental 
work,  or  emotional  excitement,  excesses,  and  irregular  living 
are  general  predisposing  factors. 

Symptoms.  Cerebral  Symptoms. — Depression  of  spirits, 
indisposition,  inability  to  concentrate  the  mind  on  one  subject 
for  any  length  of  time,  insomnia,  vertigo,  headache,  irritability 
of  temper,  and  hysterical  manifestations. 

Spinal  Symptoms. — Sometimes  these  predominate,  when  the 
condition  is  termed  spinal  irritation,  and  its  chief  manifesta- 
tions are :  Pain  in  the  back,  spots  of  tenderness  along  the 
spine,  weakness  of  the  extremities,  great  prostration  after 
moderate  exertion,  and  various  subjective  phenomena,  such  as 
numbness,  tingling,  formication,  and  neuralgic  pains. 

Gastro-intestinal  Symptoms. — Anorexia,  coated  tongue,  and 
constipation. 

Circulatory  Symptoms. — Palpitation,  cold  extremities,  and 
sometimes  violent  pulsation  of  the  aorta. 

Sexual  Symptoms. — In  females,  amenorrhcea  or  dysmenor- 
rhoea ;  in  males,  impotence  or  spermatorrhoea. 

The  disease  is  inseparably  associated  with  cerebro-spinal 
anaemia,  hysteria,  and  hypochondriasis. 

Diagnosis.  —  The  diagnosis  is  rarely  difficult.  Before 
relegating  a  case  to  this  class,  care  must  be  taken  to  exclude 
organic  disease,  and  such  general  disorders  as  lithcemia. 


396  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Prognosis. — When  the  cause  can  be  removed  and  the 
patient  controlled,  the  prognosis  is  favorable. 

Treatment.— The  treatment  is  largely  hygienic  and  die- 
tetic, and  will  vary  considerably  in  different  cases.  Where 
there  has  been  inactivity,  regulated  physical  exercise  will  be 
of  great  value;  on  the  other  hand,  the  weak  and  anaemic  will 
require  rest.  In  the  latter  case,  the  plan  of  treatment  intro- 
duced by  S.  Weir  Mitchell,  and  known  as  the  "  rest-cure," 
often  gives  brilliant  results.  In  all  cases  careful  attention 
must  be  given  to  the  diet,  bathing,  and  clothing,  and  the 
patient  assured  that  he  is  suffering  from  no  incurable  disease. 
Frequent  bathing  with  salt  water,  followed  by  friction  of  the 
skin,  will  often  add  to  the  general  vigor.  Tobacco  and  alco- 
hol must  be  interdicted,  and  tea  and  coffee  used  very  sparingly. 
Tonics  like  iron,  arsenic,  quinine,  strychnine,  and  phosphorus 
are  often  indicated. 

CHOREA. 

(Chorea  Minor,  St.  Vitus' s  Dance.) 

Definition. — A  nervous  affection  occurring  especially  in 
children,  and  characterized  by  irregular  movements  which  in- 
crease under  excitement  and  cease  during  sleep. 

Etiology. — Childhood  (between  five  and  fifteen),  female 
sex,  season  (spring),  nervous  temperament,  and  the  rheumatic 
diathesis  are  general  predisposing  factors.  It  sometimes  de- 
velops suddenly  after  mental  or  emotional  excitement,  such  as 
anxiety,  fear,  or  grief.  It  may  be  excited  by  reflex  irritation, 
as  an  adherent  prepuce,  intestinal  parasites,  etc.  It  not  infre- 
quently develops  in  the  course  of  pregnancy. 

Pathology. — It  is  customary  to  look  upon  chorea  as  a 
neurosis,  since  no  constant  lesions  have  been  discovered  to 
account  for  its  clinical  manifestations.  In  some  cases  endo- 
carditis, and  emboli  in  the  minute  cerebral  vessels  have  been 
discovered,  but  their  relation  to  chorea  has  not  yet  been  de- 
termined.    A  microbic  origin  has  been  suggested. 

Symptoms. — The  first  manifestations  are  usually  restlessness 
and  awkwardness  in  movement.  The  child  cannot  remain 
still,  but  is  constantly  raising  its  shoulders,  jerking  its  head, 


CHOEEA.  397 

twisting  its  fingers,  or  shuffling  its  feet.  Frequently  these 
symptoms  develop  so  insidiously  that  the  disease  is  not  recog- 
nized, and  the  child  is  punished  for  being  fidgety. 

When  the  disease  is  fully  established  the  disorderly  move- 
ments become  more  marked,  and  may  be  confined  to  one 
member  or  may  involve  the  entire  body.  When  the  facial 
muscles  are  affected,  the  most  grotesque  expressions  are  pro- 
duced ;  involvement  of  the  arms  may  interfere  with  eating 
and  dressing ;  when  the  legs  suffer  the  gait  becomes  jerking 
and  stumbling  ;  involvement  of  the  larynx  causes  stammering ; 
and  spasm  of  the  muscles  of  deglutition  induces  difficult 
swallowing  and  choking-spells.  When  the  attention  is  directed 
to  the  movements  they  invariably  grow  worse,  but  they 
dimmish  during  repose  and  cease  entirely  during  sleep. 
Sometimes,  in  addition  to  the  involuntary  movements,  there  is 
a  distinct  loss  of  power  in  the  affected  members.  The  general 
health  is  usually  more  or  less  impaired.  The  child  is  anaemic; 
the  temper  is  irritable ;  and  the  mental  power  deficient.  Aus- 
cultation of  the  heart  often  detects  a  murmur  which  may  be 
either  an  expression  of  ansemia  or  of  complicating  endocarditis. 

In  some  cases  (chorea  insaniens)  the  movements  are  so 
violent  that  the  patient  is  unable  to  walk,  eat,  or  even  to  lie 
down.  Fever  develops,  and  ultimately  the  mind  becomes  de- 
lirious. Death  frequently  results  from  exhaustion.  This  form 
is  usually  observed  in  adults,  and  especially  in  primipar?e. 

Diagnosis. — The  recognition  of  chorea  is  rarely  attended 
with  difficulty.  Disseminated  spinal  sclerosis  may  be  dis- 
tinguished by  the  presence  of  nystagmus,  a  scanning  speech, 
increased  reflexes,  and  a  rhythmical  tremor  which  is  only  ex- 
cited by  movement. 

Prognosis. — In  simple  chorea  recovery  usually  follows  in 
the  course  of  two  or  three  months.  Death  from  heart  com- 
plications is  a  rare  termination.  Relapses  are  not  infrequent. 
Among  the  possible  sequelse  may  be  mentioned  imbecility  and 
chronic  chorea. 

Chorea  insaniens  frequently  terminates  fatally  through  ex- 
liaustion. 

Treatment. — Rest  of  body  and  mind  is  an  essential  ele- 
ment of  the  treatment.     The  child  should   be  taken   from 


398  DISEASES  OF  THE   NERVOUS  SYSTEM. 

school  and  placed  under  the  most  favorable  hygienic  condi- 
tions. Careful  search  should  be  made  for  reflex  irritation, 
such  as  adherent  prepuce,  intestinal  parasites,  eye-strain,  etc. 
All  excitement  must  be  avoided.  Amusement  in  the  open  air 
when  the  weather  is  fine  is  to  be  recommended.  As  the  child 
is  generally  aneemic,  iron  is  indicated  in  the  majority  of  cases. 
Among  the  special  remedies  arsenic  holds  the  first  place.  Fow- 
ler's solution  may  be  given  in  doses  of  two  drops  thrice  daily, 
gradually  increased  to  eight  or  ten  drops  thrice  daily.  Among 
other  remedies  may  be  mentioned  the  fluid  ext.  of  cimicifuga 
("Ix  increased  to  3j  thrice  daily),  hyoscyamine  (gr.  jio  ioq)> 
and  quinine  (gr.  iij— v  every  two  or  three  hours). 

In  Chorea  insaniens  forced  feeding  should  be  resorted  to. 
Morphine  and  other  sedatives  may  be  employed  hypodermi- 
cally.  Chloroform  may  be  required  to  control  temporarily 
the  movements.  Severe  cases  of  chorea  complicating  preg- 
nancy will  call  for  the  induction  of  premature  labor. 

PARA1.YSIS  AGITA]?^S. 

(Peirkinson's  Disease,  Shaking  Palsy.) 

Definition. — A  chronic  nervous  disease,  characterized  by  a 
fine,  slowly-spreading  tremor,  muscular  weakness  and  rigidity, 
and  a  peculiar  gait,  termed  festination. 

Etiology. — Advanced  life,  a  neuropathic  tendency,  mental 
strain,  heredity,  and  exposure  to,  cold  and  wet  are  predisposing 
factors.  It  sometimes  develops  suddenly  after  intense  mental 
or  emotioual  excitement. 

Pathology^. — The  pathology  is  unknown.  The  lesions 
found — degeneration  of  arterioles,  perivascular  sclerosis,  pig- 
mentation of  ganglionic  cells — are  similar  to  those  induced  by 
senility. 

Symptoms, — In  some  cases  the  onset  is  abrupt,  but  more 
commonly  the  disease  develops  insidiously.  The  first  symptom 
is  usually  a  fine  tremor  beginning  in  the  hand  or  foot,  which 
may  slowly  spread  until  it  involves  all  the  members;  the 
head  is  rarely  affected.  At  first  the  tremor  may  be  parox- 
ysmal, but  as  the  disease  advances  it  becomes  almost  continuous. 
Excitement  increases  it,  but  it  is  noteworthy  that  physical 
effort  temporarily  diminishes  or  checks  it     The  face  becomes 


PARALYSIS  AGITA^S.  399 

expressionless,  and  the  speech  slow  and  measured.  Later, 
muscular  rigidity  develops ;  the  head  is  bowed,  the  body  bent 
forward,  the  ai-ms  flexed,  the  thumbs  turned  into  the  palms 
and  grasped  by  the  fingers,  and  the  knees  slightly  bent.  At 
this  time  the  gait  is  characteristic  :  the  steps  grow  faster  and 
faster,  the  body  inclines  more  and  more  forward  until  the 
patient  falls,  seeks  support  in  some  neighboring  object,  or 
straightens  himself  by  a  supreme  effort  of  the  will.  The  term 
festination  has  been  applied  to  this  peculiar  gait.  Occasionally 
a  tendency  to  fall  backwards — retropulsion — replaces  festina- 
tion. The  rigidity  and  muscular  weakness  render  all  move- 
ments slow  and  labored. 

Intelligence  is  usually  good.  There  is  no  anaesthesia,  but 
there  are  various  manifestations  of  parsesthesia,  such  as  numb- 
ness and  tingling ;  a  sensation  of  heat  is  especially  noted.  In 
some  cases  free  perspiration  has  been  observed. 

Diagnosis. — The  tremor,  rigidity,  weakness,  flexion  of  the 
body  and  members,  lack  of  facial  expression,  and  festination 
are  the  diagnostic  features.  In  some  cases  the  tremor  is  absent. 
Paralysis  agitans  must  be  distinguished  from  disseminated 
sclerosis.  In  the  latter  the  tremor  is  coarse,  is  frequently  ab- 
sent when  the  patient  is  quiet,  and  is  made  worse  by  efforts  to 
control  it ;  cerebral  symptoms  are  generally  present ;  nystag- 
mus is  often  noted ;  and  the  attitude  and  gait  are  entirely 
different  from  those  of  paralysis  agitans. 

Prognosis. — Recovery  rarely,  if  ever,  occurs.  In  some 
cases,  after  reaching  a  certain  point,  the  disease  remains  sta- 
tionary.    The  progress  is  slow  and  the  duration  indefinite. 

Treatment. — Measures  intended  to  improve  the  tone  of 
the  system  are  indicated ;  these  are  :  A  regulated  diet,  rest  of 
body  and  mind,  frequent  bathing  followed  by  friction  of  the 
skin,  and  the  use  of  such  tonics  as  iron,  arsenic,  and  phos- 
phorus. The  rigidity  and  tremors  are  sometimes  improved  by 
massage  and  electricity.  Among  the  remedies  recommended 
for  the  tremors  are  bromide  of  potassium,  hyoscyamine 
(gr.  Y^),  and  hyoscine  (gr.  y^),  but  the  improvement  follow- 
ing their  use  is  only  slight  and  temporary. 


400  DISEASES   OF   THE    NERVOUS   SYSTEM. 

ABTISANS'  CRAMP. 

Definition. — A  spasmodic  affection  of  the  muscles  in- 
duced by  prolonged  work  requiring  delicate  coordination,  and 
occurring  only  in  the  performance  of  that  particular  work. 

Etiology. — It  is  more  common  in  men  than  in  women, 
and  the  nervous  temperament  predisposes  to  its  development. 
The  occupations  in  which  it  is  most  apt  to  occur  are  writing, 
piano-playing,  sewing,  and  telegraphing. 

Pathology. — The  disease  is  evidently  not  peripheral,. for 
when  the  other  hand  is  substituted  the  condition  soon  develops 
in  that  member.  It  is  probably  dependent  upon  unnatural 
irritability  of  the  nerve-centres. 

Writers'  Cramp. 

(Graphospasm,  Scriveners'  Palsy.) 

Symptoms. — The  condition  usually  begins  with  a  sense  of 
fatio-ue,  weiffht,  or  actual  pain  in  the  affected  muscles.  Soon 
the  fingers  are  seized  with  a  tonic  or  clonic  spasm  whenever 
the  pen  is  grasped  (spastic  form).  In  some  cases  the  hand 
when  put  into  use  becomes  the  seat  of  a  decided  tremor 
(tremulous  form) ;  in  a  third  group  of  cases  the  chief  phe- 
nomena are  excessive  weakness  and  fatigue,  which  disappear 
as  soon  as  the  pen  is  laid  aside  (paralytic  form). 

PnoGNOSis. — Guardedly  favorable.  The  disease  is  obsti- 
nate, but  cure  generally  follows  protracted  rest. 

Treatment. — Absolute  rest  is  the  essential  element  of 
treatment.  The  general  condition  should  be  improved  by 
iron,  arsenic,  strychnine,  and  cod-liver  oil.  Massage,  electricity, 
and  passive  movements  give  good  results. 

TETAJVY. 

(Tetanilla,  Intermittent  Tetanus.) 

Definition. — A  nervous  affection,  characterized  by  tonic 
spasms  which  are  usually  paroxysmal  and  involve  the  ex- 
tremities. 

Etiology. — It  is  most  frequently  observed  in  the  young. 
In  women  it  is  frequently  associated  with  pregnancy  or  lacta- 


thomsen's  disease.  401 

tion.  It  is  sometimes  excited  by  exposure,  emotional  excite- 
mentj  or  one  of  the  infectious  fevers.  An  epidemic  form  has 
been  described,  but  some  of  the  outbreaks  seem  to  have  been 
hysterical.  A  very  grave  form  has  been  induced  by  thyroid- 
ectomy and  by  lavage  in  gastric  dilatation. 

Symptoms. — The  patient  is  seized  with  bilateral  tonic 
spasms  in  the  arms  and  legs.  The  jaws  are  rarely  involved. 
The  contractions  are  usually  paroxysmal  and  are  attended  with 
pain.  As  was  pointed  out  by  Trousseau,  they  can  be  induced 
by  pressure  over  the  arteries  and  nerves  of  the  affected  limb. 
The  electro-contractility  of  the  muscles  is  greatly  exaggerated. 
There  may  be  slight  oedema.  Sensation  is  not  disturbed  ;  the 
mind  is  clear  ;  and  fever  is  slight  or  entirely  absent. 

Diagnosis. — Hysteria  may  be  distinguished  from  tetany  by 
the  history,  the  unilateral  character  of  the  contractions,  the 
absence  of  muscular  excitability  and  of  Trousseau's  sign. 

Tetanus. — In  this  disease  the  spasms  are  continuous  and 
early  involve  the  jaws  and  trunk. 

Prognosis. — Usually  favorable.  Attacks  following  thy- 
roidectomy and  lavage  sometimes  prove  fatal. 

Treatment. — Good  hygiene  ;  tonics  ;  electricity ;  sedatives 
like  bromide  of  potassium,  belladonna,  and  chloral.  Warm 
or  cold  baths,  followed  by  friction. 

THOMSEN'S  DISEASE. 

(Congenital  Myotonia.) 

Definition. — A  disease  confined  to  certain  families,  and 
characterized  by  tonic  spasms  of  the  muscles,  induced  by 
voluntary  movements. 

Etiology. — The  disease  is  usually  congenital,  and  trans- 
mitted from  one  generation  to  another.  Several  members  of 
the  same  family  are  commonly  affected. 

Pathology. — Unknown. 

Symptoms. — The  disease  appears  in  early  childhood,  and  is 
manifested  by  a  tonic  spasm  of  the  muscles  every  time  they 
are  put  in  use  ;  this  is  especially  marked  after  periods  of  in- 
activity. In  a  few  moments  the  rigidity  wears  away  and  the 
movements  become  free.  From  repeated  contractions  the 
26 


402  DISEASES   OF  THE  NERVOUS  SYSTEM. 

muscles  become  firm  and  extremely  well  developed.  Uuder 
electrical  stimulation  the  muscles  contract  and  relax  slowly. 

Prognosis. — Incurable. 

Treatment.  —  The  condition  improves  under  physical 
exercise. 

EXOPHTHALMIC  GOITRE. 

(Graves's  Disease,  Basedo'w's  Disease.) 

Definition. — A  nervous  affection,  characterized  by  pro- 
trusion of  the  eyeballs,  enlargement  of  the  thyroid  gland,  and 
palpitation. 

Etiology. — Early  adult  life,  female  sex,  and  nervous  tem- 
perament are  the  predisposing  causes.  It  sometimes  develops 
suddenly  under  emotional  excitement,  such  as  fright,  grief, 
and  anxiety. 

Pathology. — In  most  eases  no  lesions  are  found  after 
death  to  account  for  the  symptoms.  It  has  generally  been 
regarded  as  a  disease  of  the  sympathetic  system,  and  in  some 
instances  changes  have  been  found  in  the  cervical  ganglia; 
but  the  mental  phenomena  and  the  accelerated  pulse  cannot 
be  explained  on  the  theory  of  sympathetic  paralysis.  The 
prominence  of  the  eyeballs  is  for  the  most  part  due  to  dilata- 
tion of  the  vessels  in  the  back  of  the  orbits ;  and  the  enlarge- 
ment of  the  thyroid  gland  is  due  to  a  similar  condition. 

Symptoms.  Cardiac  Phenomena.  —  Acceleration  of  the 
pulse  (100-150)  and  palpitation,  both  greatly  exaggerated  by 
excitement ;  hypertrophy  of  the  heart  from  its  rapid  action ; 
occasionally  a  soft  systolic  murmur  at  the  apex. 

Ocular  Phenomena. — Bilateral  protrusion  of  the  eyeballs; 
Graefe's  sign,  which  consists  in  a  failure  of  the  upper  lid  to 
follow  the  eyeball  when  the  latter  is  directed  downwards ; 
widening  of  the  palpebral  angle  (Stellwag's  sign).  Vision  is 
usually  unimpaired. 

Thyroid  Phenomena. — Enlargement  of  the  thyroid  is  often 
the  last  symptom  to  appear;  one  or  both  lobes  of  the  gland 
may  be  affected.  Inspection  reveals  enlargement  with  pulsa- 
tion ;  palpation  detects  a  soft  swelling  and  a  purring  thrill ; 
auscultation  may  yield  a  bruit 


Raynaud's  disease.  403 

Nervous  Phenmnena. — The  following  are  sometimes  ob- 
served :  A  tremor  of  the  hands  or  of  the  entire  body ;  hypo- 
chondriasis ;  acute  mania ;  or  vitiligo  and  chloasma. 

General  Phenomena.  —  Anaemia,  failure  of  health  and 
strength,  and  slight  febrile  paroxysms. . 

Diagnosis. — It  should  be  borne  in  mind  that  one  of  the 
three  important  symptoms  may  be  absent  throughout  the 
disease.  In  some  cases  palpitation  and  throbbing  of  the 
cervical  vessels  may  be  the  only  phenomena. 

Goitre  may  be  distinguished  from  exophthalmic  goitre  by  the 
absence  of  cardiac,  ocular,  and  nervous  symptoms. 

Prognosis. —  The  disease  generally  runs  a  protracted  course. 
Some  cases  recover  entirely ;  many  improve  and  subsequently 
relapse ;  a  few  die,  after  a  short  illness,  from  heart  failure  or 
acute  mania. 

Treatment. — The  general  nutrition  must  be  improved  by 
rest,  a  liberal  diet,  and  the  use  of  such  tonics  as  iron,  quinine, 
and  arsenic.  The  application  of  mild  galvanic  currents  to  the 
neck  is  often  very  useful.  Wheu  the  palpitation  is  marked, 
prompt  relief  often  follows  absolute  rest  and  the  application 
of  an  ice-bag  to  the  preecordia.  The  most  reliable  internal 
remedies  are  strophanthus,  digitalis,  belladonna,  and  ergot. 
Bromide  of  potassium  is  sometimes  useful  in  controlling  the 
nervous  symptoms.     Thyroid  extract  is  harmful. 

Operative  treatment  is  hazardous,  though  not  infi'equently 
followed  by  excellent  results. 

KAYl^AUD'S  DISEASE. 

(Symmetrical  Gangrene.) 

Definition. — A  vaso-motor  neurosis,  characterized  by  local 
anaemia,  congestion,  or  gangrene. 

Etiology. — The  cause  is  unknown.  The  disease  probably 
consists  in  a  local  spasm  or  paresis  of  the  vessels. 

Symptoms. — In  one  form  the  part,  usually  the  finger,  be- 
comes extremely  pale,  cold,  and  anaesthetic  (local  syncope). 
After  a  variable  time  these  phenomena  disappear  and  are  fol- 
lowed by  redness,  heat,  and  tingling ;  such  attacks  may  be 
excited  by  cold,  and  come  and  go  without  damaging  the  part. 


404  DISEASES   OF  THE  NERVOUS  SYSTEM. 

In  another  form  the  aiFected  part  becomes  swollen,  dark  red, 
and  painful  {local  asphyxia),  and  if  the  attack  persists  bullae 
may  appear  and  gangrene  develop.  The  gangrenous  areas 
are  often  symmetrical,  involving  a  finger  on  each  hand,  a  toe 
on  each  foot,  or  both  ears.  Hsemoglobinuria  may  occur  in,  or 
replace,  an  attack. 

Prognosis. — The  attacks  persist,  but  life  is  not  endangered. 
In  rare  instances  extensive  gangrene  develops  and  is  followed 
by  death. 

Treatment. — Patients  liable  to  attacks  should  be  well 
protected  against  cold.  Tonics  are  often  indicated.  Frequent 
bathing  followed  by  friction  is  useful.  Raynaud  advises  the 
use  of  a  continuous  current,  on-e  pole  over  the  spine  and  the 
other  over  the  affected  area.    Nitro-glycerine  may  prove  useful. 

ACUTE  AJVGIO-NEUKOTIC  (EDEMA. 

Definition. — A  neurosis  characterized  by  transient  circum- 
scribed oedema  developing  without  obvious  cause. 

Etiology. — Beyond  a  distinct  hereditary  tendency  nothing 
is  known  of  its  cause.  According  to  Quincke,  there  is  a  tem- 
porary vaso-motor  dilatation  of  the  vessels  followed  by  the 
transudation  of  serum. 

Symptoms. — (Edematous  swelling  suddenly  appears  in  some 
part  of  the  body,  particularly  in  the  face  and  hands.  Coinci- 
dent with  the  oedema  there  may  be  marked  gastro-intestinal 
symptoms  such  as  vomiting,  gastralgia,  and  colic.  The  disease 
is  allied  to  urticaria  and  the  latter  may  precede  the  outbreak. 

The  attacks  may  occur  at  intervals  of  a  few  weeks. 

Prognosis. — The  peculiar  tendency  persists ;  unless  the 
larynx  is  involved,  it  is  unattended  with  danger. 

Treatment. — General  tonics,  like  iron,  quinine,  and  strych- 
nine are  sometimes  useful. 

MTX(EDEMA. 

Definition. — A  constitutional  affection,  characterized  by 
mucoid  degeneration  of  tlie  subcutaneous  tissues,  atrophy  of 
the  tljyroid  gland,  and  mental  impairment. 


FACIAL.   HEMI-ATEOPHY.  405 

Etiology. — The  disease  is  much  more  frequent  in  women 
than  in  men.  It  is  occasionally  hereditary.  It  usually  devel- 
ops in  middle  life.  The  immediate  cause  is  atrophy  of  the 
thyroid  gland. 

A  congenital  form  of  myxoedema  is  observed  in  cretinism, 
and  an  analogous  condition  (operative  myxoedema  or  cachexia 
strumipriva)  frequently  follows  total  extirpation  of  the  thyroid 
gland. 

Symptoms. — It  is  manifested  by  a  gradual  swelling,  partic- 
ularly marked  in  the  face,  supraclavicular  regions,  and  hands. 
Unlike  oedema,  the  parts  do  not  pit  on  pressure,  but  are  firm 
and  elastic.  The  skin  is  dry  and  harsh.  The  hair  is  dry  and 
brittle.  The  thyroid  gland  is  atrophied.  A  pecular  slowness 
in  thought,  speech,  and  movements  is  a  characteristic  symp- 
tom. The  temperature  of  the  body  is  subnormal.  There  is 
impairment  of  the  special  senses.  Sensory  phenomena  are 
common,  such  as  coldness,  numbness,  and  tingling.  The  urine 
is  often  increased  in  quantity,  and  occasionally  contains  albu- 
min, sugar,  and  tube-casts. 

Complications. — Insanity,  tuberculosis,  exophthalmic  goi- 
tre, and  nephritis. 

Diagnosis. — The  mental  dulness,  the  extreme  dryness  of 
the  skin,  the  absence  of  pitting  on  pressure  will  separate  myx- 
oedema from  Bright's  disease  with  oedema. 

Progxosls. — The  disease  was  formerly  considered  incurable, 
but  it  is  now  known  that  marked  amelioration  or  even  a  cure 
can  be  effected  by  appropriate  treatment. 

Treatment. — Murray  was  the  first  to  demonstrate  the  value 
of  thyroid  juice  in  myxoedema.  A  glycerine  extract  or  a  dried 
extract  of  the  gland  may  be  employed ;  the  latter  is  very  effi- 
cient in  doses  of  one  grain,  gradually  increased  to  five  grains, 
three  times  a  day.  Residence  in  a  warm  climate  is  desirable. 
Warm  baths  followed  by  friction  and  massage  are  useful. 

FACIAL  HEMI- ATROPHY. 

(Unilateral  Progressive  Atrophy  of  the  Face.) 

Definition. — A  rare  affection,  characterized  by  progres- 
sive wasting  of  tissues — bones  and  soft  parts — on  one  side  of 
the  face. 


406  DISEASES   OF  THE   NERVOUS  SYSTEM. 

Etiology. — The  disease  usually  develops  in  childhood.  It 
has  been  excited  by  injury  of  the  lace. 

Pathology.  —In  the  few  cases  examined  chronic  trigeminal 
neuritis  or  lesions  of  the  Gasserian  ganglion  have  been  dis- 
covered. 

Symptoms. — The  first  phenomenon  is  often  discoloration  of 
the  skin ;  this  is  soon  followed  by  a  slow  wasting  of  all  the 
tissues  on  the  affected  side  of  the  face.  The  hair  falls ;  the 
eye  is  sunken  ;  and  the  teeth  drop  out. 

Prognosis. — The  disease  is  progressive  and  incurable. 

ACROMEGALIA. 

(Marie's  Disease,  Pachyacria.) 

Definition. — A  nutritional  disease,  characterized  by  en- 
largement of  the  bones  and  overlying  tissues,  chiefly  of  the 
hands,  feet,  and  face. 

Etiology. — Unknown.  It  usually  develops  in  early  life. 
A  loss  of  pituitary  secretion  is  the  probable  cause. 

Pathology. — Examination  of  the  bones  reveals  a  true 
hypertrophy,  particularly  of  the  cancellous  structures.  In 
some  cases  the  pituitary  body  has  been  hypertrophied  and  the 
thymus  gland  persistent;  in  a  few  the  thymus  or  thyroid  gland 
has  been  diseased. 

Symptoms. — The  hands  and  feet  are  considerably  enlarged, 
especially  in  breadth  ;  the  fingers  and  toes  are  stumpy  and  the 
nails  are  flat  and  small.  Hypertrophy  of  the  inferior  maxil- 
lary bone  leads  to  elongation  of  the  face  and  protrusion  of  the 
lower  jaw.  The  lips  are  large  and  everted.  Among  occa- 
sional symptoms  may  be  mentioned  spinal  curvature,  polyuria, 
glycosuria,  persistent  headache,  deafness,  blindness  from 
atrophy  of  the  optic  nerve,  loss  of  sexual  power,  and  in  women, 
menstrual  disorders. 

Diagnosis. — Acromegalia  might  be  mistaken  for  myxoe- 
dema,  but  in  the  latter  the  soft  parts  only  are  involved ;  the 
skin  is  firm  and  adherent,  instead  of  soft  and  mobile  as  in 
acromegalia  ;  and  the  face  is  round. 

In  Paget' s  osteitis  deformans  the  long  bones  are  especially 
involved,  and  are  not  only  enlarged,  but  considerably  deformed ; 
and  the  face  has  a  peculiar  triangular  shape. 


StJNSTEOKE.  407 

Prognosis. — The  aifection  is  incurable,  out  the  duration  is 
indefinite. 

Teeatment. — So  far,  remedies  have  been  futile. 

SUNSTROKE. 

(Heat-stroke,  Thermic  Fever,  Coup  de  Soleil,  Insolation,  Heat- 
exhaustion.) 

Definition. — An  affection  resulting  from  exposure  to  ex- 
cessive heat. 

Varieties. — Two  varieties  are  observed :  Thermic  fever 
and  heat-exhaustion. 

Thermic  Fever. 

Pathology. — After  death  from  thermic  fever  rigor  mortis 
develops  early  and  is  marked.  The  various  organs,  especially 
the  brain,  are  deeply  congested.  The  left  ventricle  is  firmly 
contracted,  and  the  right  is  dilated  and  filled  with  blood.  The 
blood  is  dark  and  uncoagulated.  Microscopic  examination 
of  the  tissues  reveals  parenchymatous  degeneration,  or  cloudy 
swelling. 

Symptoms. — Prodromes  are  frequently  present  and  consist 
of  exhaustion,  vertigo,  nausea,  and  headache.  These  symp- 
toms are  followed  by  coma,  and  in  this  state  the  face  is  flushed ; 
the  eyes  are  injected ;  the  skin  is  dry  and  burning ;  the  tem- 
perature ranges  from  106°  to  112°  ;  the  pupils  are  contracted; 
the  respirations  are  rapid  and  noisy ;  and  the  pulse  is  full  and 
rapid.  Unless  the  temperature  soon  falls  the  respirations 
become  shallow,  the  pulse  weakens,  and  death  results  in  a 
few  hours.  There  is  a  very  malignant  form  in  which  the 
patient  is  suddenly  stricken  comatose  and  dies  in  a  few  hours 
from  cardiac  failure. 

Sequels.  —  Meningitis  ;  epilepsy  ;  insanity ;  failure  of 
memory  ;  and  extreme  sensitiveness  to  high  temperature. 

Diagnosis. — The  conditions  under  which  the  coma  has  de- 
veloped, together  with  the  extremely  high  temperature  of  the 
body,  will  serve  to  distinguish  sunstroke  from  apoplexy,  alco- 
holism, and  uraemia. 


408  DISEASES    OF    THE   NERVOUS    SYSTEM. 

Prognosis. — Veiy  guarded.  Probably  forty  per  cent, 
perish. 

Treatment. — The  patient  should  be  promptly  placed  in  a 
bath  of  ice  water  and  should  be  rubbed  with  ice.  Ice-water 
enemata  are  also  useful.  Antipyrin  has  been  administered 
subcutaneously  with  good  results.  When  the  pulse  is  full 
and  strong  venesection  may  be  a  valuable  adjunct  to  the  anti- 
pyretic treatment. 

Heat-exhaustion. 

Pathology. — According  to  Wood,  heat-exhaustion  depends 
on  a  vaso-motor  paresis,  as  a  result  of  which  there  is  a  deter- 
mination of  blood  from  the  brain  and  surface  of  the  body  to 
the  great  bloodvessels  of  the  abdomen. 

Symptoms. — The  mind  is  dazed,  but  consciousness  is  not 
lost ;  the  surface  is  pale  and  cold  ;  the  skin  is  moist ;  the  res- 
pirations are  shallow  and  hurried ;  and  the  pulse  is  rapid  and 
feeble. 

Prognosis. — Recovery  soon  follows  under  appropriate  treat- 
ment. 

Treatment. — The  patient  should  be  covered  with  hot 
blankets,  and  hot  bottles  should  be  placed  near  the  feet. 
Brandy,  ammonia,  and  strong  coffee  are  useful  stimulants. 
Strychnine  hypodermically  is  a  very  efficient  remedy. 

ALCOHOLISM. 

(Dipsomania.) 

Acute  Alcoholism. — After  excessive  indulgence  in  alcohol 
the  following  symptoms  are  observed:  Flushing  of  the  face, 
quickening  of  the  pulse,  and  mental  exhilaration,  followed  by 
incoherent  speech,  loss  of  coordination,  vomiting,  delirium, 
slow  pulse,  subnormal  temperature,  and,  finally,  stupor  and 
coma.  Occasionally  the  coma  is  replaced  or  interrupted  by 
convulsive  seizures.  In  the  majority  of  cases,  recovery  follows 
in  the  course  of  a  day  or  two  ;  but  sometimes  the  coma  deepens 
and  death  results. 

Ghronic  Alcoholism. — This  condition  is  characterized  by  a 


ALCOHOLISM.  409 

fine  tremor,  mental  impairment,  disturbed  sleep,  injection  of 
the  conjunctivae,  redness  of  the  nose  (acne  rosacea),  and  the 
symptoms  of  chronic  gastro-intestinal  catarrh,  namely,  ano- 
rexia, coated  tongue,  fetid  breath,  nausea,  vomiting,  fulness 
and  distress  after  eating,  and  constipation  alternating  with 
diarrhoea.  When  the  habit  is  long  continued,  atheroma  of  the 
arteries,  cirrhosis  of  the  liver,  and  chronic  interstitial  nephritis 
are  apt  to  develop. 

A  very  common  complication  of  chronic  alcoholism  is 
delirium  tremens  ("mania  a  potu).  This  condition  usually 
follows  a  protracted  debauch,  or  spree,  or  is  excited  by  an  in- 
jury or  some  intercurrent  disease.  Its  chief  manifestations  are  : 
Mental  excitement,  insomnia,  incoherent  speech,  disordered 
intellect,  tremors,  and  hallucinations,  usually  of  sight  and  hear- 
ing. The  last  are  of  a  terrifying  character  ;  the  patient  hears 
threatening  voices,  or  sees  repulsive  creatures — snakes,  rats, 
loathsome  insects,  or  demons — peering  at  him  from  behind 
every  piece  of  furniture.  In  some  cases  the  terror  excited  by 
these  hallucinations  is  so  great  that,  in  a  fit  of  maniacal  ex- 
citement, the  patient  rushes  out  into  the  street  or  jumps  from 
the  window.  The  pulse  is  rapid  and  feeble ;  the  appetite  is 
entirely  lost ;  the  bowels  are  constipated ;  and  the  temperature 
usually  elevated  (101° -103°). 

In  favorable  cases,  in  the  course  of  a  few  days  or  a  week, 
the  excitement  abates,  the  appetite  returns,  sleej)  is  restored, 
and  convalescence  established.  In  unfavorable  cases,  typhoid 
symptoms  are  apt  to  develop ;  these  are :  Irregular  fever, 
weak  pulse,  dry,  brown  tongue,  stupor,  subsultus  tendinum, 
carphologia,  and  finally,  complete  coma. 

Among  other  complications  or  sequelae  of  dipsomania  may 
be  mentioned :  Multiple  neuritis,  pneumonia,  epilepsy,  chronic 
meningitis,  paretic  dementia,  and  various  psychoses. 

Diagnosis. — The  coma  of  alcoholism  must  be  distinguished 
from  the  coma  of  other  diseases.  The  history,  the  absence  of 
paralysis,  the  subnormal  temperature,  the  fact  that  the  patient 
can  be  aroused  by  screaming  in  the  ear,  or  by  firm  pressure 
over  some  sensitive  spot  like  the  supraorbital  notch,  the  odor 
on  the  breath,  and  the  absence  of  other  cause'  will  usually 
prevent  an  error  in  diagnosis. 


410  DISEASES  OF   THE   NERVOUS   SYSTEM. 

Delwium  tremens  is  recognized  by  the  history,  restlessness, 
delirium,  tremors,  and  terrifying  hallucinations. 

The  tremors  of  chronic  alcoholism  may  be  recognized  by  the 
history,  the  associated  evidence  of  alcoholism,  and  by  the  fact 
that  they  are  worse  in  the  morning,  and  improve  after  the  use 
of  the  stimulant. 

Prognosis. — In  acute  alcoholism  the  prognosis  should  be 
guardedly  favorable.  In  delirium  tremens  recovery  generally 
follows,  unless  there  is  great  debility.  In  alcoholic  pneumonia 
the  outlook  is  grave ;  recovery  is  exceptional.  In  alcoholic 
neuritis  the  symptoms  usually  subside  under  appropriate 
remedies  and  abstinence  from  the  stimulant. 

In  chronic  alcoholism  the  j)rognosis  is  generally  unfavorable. 
When  the  habit  is  fully  established,  it  is  rarely  permanently 
broken ;  temporary  improvement  is  only  too  often  followed  by 
a  relapse. 

Treatment.  Acute  Alcoholism. — The  stomach  should  be 
emptied  by  the  stomach-pump,  a  stimulating  emetic,  or  the 
hypodermic  injection  of  apomorphine  (gr.  yq— |^).  If  the  coma 
persists  and  the  pulse  weakens,  cardiac  stimulants  like 
ammonia,  strychnia,  and  digitalis  should  be  administered 
hypodermically.  Douching  and  flagellation  may  also  be 
employed  to  arouse  the  patient. 

Delirium  Tremens. — Alcohol  must  be  withheld  unless  the 
pulse  is  very  weak.  It  is  essential  that  the  patient  should 
receive  sufficient  nourishment,  for  usually  little  food  has  been 
taken  during  the  debauch  which  led  to  the  delirium.  Highly- 
seasoned  beef-tea  and  milk  with  lime-water  are  the  best  foods. 
Sleep  must  be  secured  by  chloral  (gr.  xx),  bromide  of  potas- 
sium (3SS-3J),  hyosciue  (gr.  j^),  morphine  (gr.  ^,  and  repeated 
once  or  twice),  or  paraldehyde  (3j).  When  the  pulse  is  weak 
strychnine  (gr.  -^,  repeated,  watching  the  effect)  is  often  of 
great  value.  In  most  cases  physical  restraint  is  essential ;  it 
is  best  secured  by  strapping  the  patient  to  the  bed  with  sheets. 

Chronic  Alcoholism. — It  is  necessary  that  alcohol  shall  be 
withdrawn ;  the  rapidity  with  which  this  can  be  accomplished 
will  depend  on  the  circumstances.  In  most  cases  the  tempta- 
tion to  drink  is  so  strong  that  confinement  in  an  inebriate 
asylum  is  essential  to  the  success  of  the  treatment.     Various 


OPIUM-POISONING.  411 

substitutes  have  been  recommended  for  alcohol,  among  which 
may  be  mentioned  bromide  of  potassium,  chloral,  cocaine, 
hyoscine,  and  cannabis  indica.  As  a  rule,  they  accomplish 
little  beyond  quieting  the  patient  and  occasionally  securing 
sleep.  The  diet  should  be  nutritious,  and  carefully  adapted 
to  the  condition  of  the  stomach,  which  is  usually  the  seat  of 
chronic  catarrh.  Tonics  like  iron,  quinine,  and  strychnine  are 
often  indicated.  Graduated  physical  exercise  is  sometimes  of 
decided  value. 

OPIUM-POISOIVING. 

Acute  Poisoning.  Syjiptoms.  —  A  stage  of  excitement  is 
followed  by  stupor,  coma,  contracted  pupils,  slow  respirations, 
muscular  relaxation,  and  a  slow  pulse.  In  the  final  stage  the 
respirations  become  shallow  and  irregular,  the  pulse  rapid  and 
feeble,  and  the  pupils  dilated. 

Treatment, — The  stomach  should  be  emptied  by  a  stimu- 
lating emetic  or  the  stomach-pump.  Strong  coifee  may  be 
given  by  the  mouth.  The  patient  should  be  aroused  by 
flagellation,  douching,  forced  walking,  or  the  electric  brush. 
The  physiological  antidotes — atropine  and  strychnine — should 
be  given  hypodermically  in  full  doses,  their  effects  being  care- 
fully watched.  Electricity  may  be  employed  to  stimulate 
respiration. 

MorpMne-habit.  [Morphinism,  Morphiomania.)  Symp- 
toms.— Anaemia,  sallow  complexion,  an  irresistible  craving 
for  the  drug,  dilated  pupils,  tremors,  loss  of  appetite,  restless- 
ness, insomnia,  mental  impaii'ment,  and  a  complete  perversion 
of  the  moral  nature. 

Treatment. — Confinement  in  an  asylum  is  nearly  always 
necessary.  The  opium  should  be  withdrawn  gradually.  Such 
substitutes  as  cocaine,  chloral,  hyoscine,  paraldehyde,  and 
sulphonal  may  be  employed  temporarily.  Respiratory  stimu- 
lants like  strychnine,  and  cardiac  stimulants  like  digitalis,  are 
often  indicated.  In  the  vast  majority  of  cases  the  habit  is 
only  suspended,  not  broken. 


412  DISEASES   OF   THE    NERVOUS    SYSTEM. 

CHRONIC  LEAD-POISONING. 

(Plumbism,  Saturnism.) 

Etiology.— ^Chronic  lead-poisoning  results  from  the  slow 
absorption  of  lead,  and  is  most  commonly  observed  in  work- 
men who  handle  the  metal.  Printers,  type-founders,  and 
workers  in  white-lead  are  especially  liable  to  be  aifected.  Oc- 
casionally it  results  from  the  use  of  water  which  has  been 
carried  through  lead  pipes  or  which  has  been  stored  in  cisterns 
lined  with  lead. 

Pathology.  —  The  muscles  are  degenerated,  and  the  pe- 
ripheral nerves  frequently  reveal  evidences  of  chronic  neuritis. 
In  cases  associated  with  marked  muscular  atrophy,  polio- 
myelitis is  discovered. 

Symptoms. — ^The  followinp;  are  the  chief  manifestations : 
Anaemia  ;  severe  colicky  pains  centering  around  the  umbilicus 
and  associated  with  retraction  and  rigidity  of  the  abdominal 
walls ;  constipation  ;  a  blue  line  on  the  gums  near  the  in- 
sertion of  the  teeth,  due  to  the  deposition  of  a  sulphuret  of 
lead ;  paralysis ;  tremors ;  intense  headache ;  pains  in  the 
joints  (arthralgia) ;  arterio-sclerosis ;  chronic  interstitial  ne- 
phritis ;  and  grave  cerebral  symptoms  (encephalopathies). 

The  Paralysis. — This  in  most  instances  involves  the  exten- 
sors of  both  forearms,  and  gives  rise  to  the  well-known  wrist- 
drop. In  advanced  cases  the  muscles  atrophy  and  yield  the 
reactions  of  desceneration.     Sensation  is  not  affected. 

Encephalopatkies. — These  are  among  the  more  rare  mani- 
festations of  plumbism,  and  consist  of  convulsions,  coma, 
delirium,  intense  headache,  and  blindness  from  atrophy  of 
the  optic  nerves. 

Prognosis. — Guardedly  favorable. 

Treatment. — Prophylaxis  consists  in  absolute  cleanliness; 
the  use  of  respirators  in  lead  factories ;  the  avoidance  of 
eating  in  an  atmosphere  laden  with  the  dust  of  the  metal ; 
and  in  the  occasional  use  of  Epsom  salts. 

The  curative  treatment  consists  in  the  administration  of 
iodide  of  potassium  (gr.  v-x  thrice  daily)  and  the  use  of 
sulphur  baths.  Constipation  should  be  relieved  by  Epsom 
salts.      The   colic  may  require    the  hypodermic  injection   of 


CHRONIC   MERCURIAL    AND    ARSENICAL    POISONING.       413 

morphine  aud  atropine,  and  the  application  of  hot  fomentations 
to  the  abdomen.  The  paralysis  generally  yields  to  massage,  the 
constant  current,  and  hypodermic  injections  of  strychnine. 

CHRONIC  DIERCURIAL  POISONING. 

Etiology — This  is  usually  observed  in  those  employed  in 
quicksilver  mines,  or  engaged  in  making  mirrors,  barometers, 
or  other  scientific  instruments  requiring  the  use  of  mercury. 

Symptoms. — Anaemia,  loss  of  flesh  and  strength,  gastro-in- 
testinal  disturbances,  and  marked  tremors.  The  latter  usually 
begin  in  the  extremities,  and  are  at  first  slight,  but  later  the 
whole  body  is  involved,  and  the  tremors  are  violent.  In  ad- 
vanced cases  they  may  continue  during  sleep.  Grave  cerebral 
symptoms  occasionally  develop,  such  as  vertigo,  headache,  im- 
pairment of  intellect,  convulsions,  paralysis,  and  coma. 

Diagnosis. — The  history,  the  marked  tremor  of  the  head, 
and  the  absence  of  the  peculiar  gait  (festination)  will  distin- 
guish it  from  paralysis  agitans.  -^ 

The  history  and  the  absence  of  nystagmus  will  distinguish 
it  from  disseminated  sclerosis. 

Treatment. — Removal  from  the  influence  of  the  metal. 
Tonics.  Iodide  of  potassium.  Electricity.  Sedatives  for  the 
tremors. 

CHRONIC  ARSENICAl.  POISONING. 

Etiology. — It  is  observed  in  workmen  employed  in  arsenic 
works  and  glass  factories.  Inhaling  the  dust  of  fabrics, 
papers,  artificial  flowers  etc.,  which  have  been  colored  with 
arsenic,  may  induce  poisoning. 

Symptoms. — Ansemia,  loss  of  flesh  and  strength,  conjunc- 
tivitis, gastro-intestinal  catarrh,  loss  of  hair,  cutaneous  erup- 
tions, and  paralysis.  The  last,  unlike  that  observed  in  lead- 
poisoning,  usually  involves  the  extensors  of  the  legs,  but  later 
it  may  also  involve  the  arms. 

Treatment. — Removal  from  the  influence  of  arsenic. 
Tonics.     Electricity  and  massage  to  the  afiected  muscles. 


DISEASES 


SKIN  AND  ITS  APPENDAGES. 


THE  COLOR  OF  THE  SKIN. 

Pallor  as  a  permanent  condition  is  generally  an  expression  of 
anaemia ;  but  it  should  be  borne  in  mind  that  in  some  cases 
the  surface  is  pale  when  the  blood  is  normally  rich  in  corpus- 
cles and  haemoglobin  ;  and  that  in  other  cases  the  surface  has 
a  natural  color  when  the  blood  is  considerably  deficient  in 
corpuscles  and  haemoglobin.  It  follows  therefore  that  an  abso- 
lute diagnosis  of  anaemia  must  rest  on  an  analysis  of  the 
blood. 

Pallor  as  a  temporary  condition  may  result  from  emotional 
excitement,  exposure  to  extreme  cold,  shock,  syncope,  or  col- 
lapse. 

Yellowness  of  the  skin  may  result  from  jaundice,  in  which 
case  the  conjunctivae  will  also  be  yellow  and  the  urine  will 
contain  bile.  Yellowness  may  also  result  from  chlorosis  or 
pernicious  ancemia,  and  in  these  cases  the  normal  color  of  the 
conjunctivae,  the  associated  symptoms  of  the  disease,  and  the 
absence  of  bile  in  the  urine  will  indicate  the  cause. 

Whiteness  of  the  Skin. — A  milk-white  hue  over  extensive 
areas  may  be  observed  in  albinism,  vitiligo,  and  in  leprosy. 

Dark-brown  or  gray  discoloration  of  the  skin  is  observed  in 
the  following  conditions  : — 

Addison's  Disease. — In  this  affection  the  skin  has  a  bronzed 
appearance,  which  is  especially  marked  on* exposed  parts  ;  the 
(414) 


THE  COLOR  OF  THE  SKIN.  415 

buccal  mucous  membrane  may  also  reveal  discolored  plaques ; 
and  there  are  in  addition  anaemia,  prostration,  and  gastric 
irritability. 

Argyria. — This  term  is  applied  to  the  dark-gray  discolora- 
tion of  the  exposed  parts  which  follows  the  prolonged  use  of 
nitrate  of  silver.  The  discoloration  is  due  to  a  deposition 
of  the  oxide  of  silver,  and  is  more  or  less  permanent.  It  is 
said  to  be  preceded  by  a  dark  line  on  the  gums,  similar  to  the 
one  observed  in  chronic  lead-poisoning.  Formerly,  when 
nitrate  of  silver  was  used  extensively  in  the  treatment  of 
epilepsy,  it  was  not  an  uncommon  condition. 

Vagabondismus. — This  term  is  applied  to  the  dark-brown 
discoloration  of  the  skin  which  follows  prolonged  exposure  to 
the  weather,  uncleanliness,  and  perhaps  the  irritation  of  the 
skin  resulting  from  pediculosis. 

Blueness  of  the  skin,  as  a  permanent  condition,  is  generally 
an  expression  of  cyanosis. 

Hardness,  or  Induration  of  the  Skin. 

Induration  of  the  skin  is  observed  in  scleroderma.  In  this 
affection  the  skin  is  tense,  hide-bound,  and  more  or  less  pig- 
mented. Induration  is  also  observed  in  myxoedema.  In  this 
condition  the  skin  is  swollen  as  in  oedema,  but  it  is  firm,  in- 
elastic, and  does  not  pit  on  pressure.  In  addition,  the  features 
are  peculiarly  broadened  and  the  mental  power  is  impaired. 
Circumscribed  patches  of  induration  are  observed  in  morphoea. 
The  circumscribed  patches,  with  hypersemic  or  pigmented 
borders,  and  the  smooth,  shiny,  atrophied  skin  are  the  diag- 
nostic features. 

(Edema,  or  dropsy  of  the  subcutaneous  tissues,  when  extreme, 
also  causes  induration. 

A  brawny,  indurated  condition  of  the  muscles,  especially  of 
the  legs,  is  frequently  observed  in  scurvy.  It  probably  results 
from  a  sanguineous  exudation.  The  anaemia,  purpuric  spots, 
and  spongy,  bleeding  gums  will  aid  in  the  diagnosis. 


416       DISEASES   OF  THE  SKIN   AND   ITS  APPENDAGES. 


(EDEMA,  OR  DROPSY  OF  THE  SUBCU- 
TAJVEOUS  TISSUES. 

CEderaa  may  be  recognized  by  a  swelling  which  pits  on 
pressure.  It  results  from  :  (1)  Venous  stasis — from  chronic 
heart,  liver,  and  lung  disease ;  and  from  local  obstruction  to 
the  venous  circulation,  as  by  a  tumor,  pregnant  uterus,  or  a 
varicose  condition  of  the  veins.  (2)  Alterations  in  the  blood 
or  capillaries,  as  in  Bright's  disease,  anaemia,  and  inflammation. 

GLOSSY  SKLN. 

"Glossy  Skin." — This  term  was  applied  by  Paget  to  indi- 
cate a  smooth,  atrophied,  and  shiny  appearance  of  the  skin. 
It  is  most  frequently  observed  after  inflammation  or  injury  of 
the  nerve-trunks.  It  is  sometimes  associated  with  an  intense 
burning  pain,  to  which  Mitchell  has  given  the  name  causalgia, 

ENLARGEMENT  OF  THE  SUPERFICIAL 
VEINS. 

Enlargement  of  the  superficial  veins  may  result  from 
chronic  heart,  lung,  or  liver  disease ;  from  the  pressure  of  a 
tumor  or  aneurism  on  deep-seated  veins ;  or,  as  a  general  con- 
dition, it  may  be  congenital  and  result  from  occlusion  of  deep 
veins. 

"  Caput  Medusae." — This  term  is  applied  to  a  circle  of  dilated 
veins  surrounding  the  umbilicus.  It  is  indicative  of  obstruc- 
tion to  the  portal  circulation,  and  may  result  from  atrophic 
cirrhosis  of  the  liver,  from  thrombosis  of  the  portal  vein,  or 
from  the  pressure  of  a  tumor  on  the  portal  vein. 

CUTANEOUS  EMPHYSEMA. 

Cutaneous  emphysema  consists  in  an  escape  of  air  into  the 
cellular  tissue.  It  is  manifested  by  a  diffuse,  pallid  swelling 
of  the  skin,  which  crackles  on  palpation  and  which  pits  on 
pressure ;  but,  unlike  oedema,  the  depression  immediately  dis- 
appears when  the  finger  is  withdrawn.     It  may  result  (1)  from 


CUTANEOUS   ERUPTIONS.  417 

traumatism  of  the  air-passages,  as  a  gunshot  wound  of  the  chest 
or  a  fracture  of  the  rib.  (2)  From  rupture  of  the  oesophagus, 
stomach,  intestines,  larynx,  trachea,  or  lungs.  The  rupture  of 
these  organs  is  usually  due  to  ulceration,  as  in  cancer  of  the 
cesophagns,  tuberculous  cavity  of  the  lung,  or  purulent  pleurisy ; 
but  occasionally  the  lung  ruptures  from  violent  strain. 

ABNORMAL,  CONDITIONS  OF  THE  NALLS. 

Atrophy  of  the  Nails. — The  nails  may  become  dry,  brittle, 
discolored,  and  cracked  in  organic  disease  of  the  spinal  cord ; 
after  inflammation  or  injury  of  the  peripheral  nerves ;  after 
prolonged  febrile  diseases,  like  typhoid  fever ;  and  in  certain 
aifections  of  the  skin  which  involve  the  matrix  of  the  nail,  as 
eczema,  psoriasis,  and  ringworm. 

Curving  of  the  Nails. — Incurvation  of  the  nails  is  generally 
associated  with  clubbing  of  the  terminal  phalanges.  It  is  ob- 
served in  phthisis,  chronic  cardiac  disease,  and  in  many  wast- 
ing diseases. 

Onychia. — Inflammation  of  the  matrix  of  the  nail  may  re- 
sult from  injury;  from  syphilis;  from  organic  disease  of  the 
spinal  cord,  as  locomotor  ataxia ;  from  arthritis  deformans ; 
and  from  cutaneous  aifections  involving  the  matrix,  as  leprosy, 
ringworm,  and  eczema. 

CUTANEOUS  ERUPTIONS. 

Macules. 

Macules  are  discolored  spots  which  are  neither  elevated  nor 
depressed. 

A  general  red  macular  ei'Uj^tion  is  observed  in  the  following 
conditions : — 

Syphilis. — Secondary  syphilis  may  manifest  itself  as  an 
eruption  of  small  red  macules.  They  are  usually  abundant 
and  frequently  cover  the  entire  body ;  they  lack  subjective 
symptoms;  they  are  usually  associated  with  the  history  or 
with  the  evidences  of  syphilis,  such  as  the  scar  of  the  chancre, 
bone-pains,  alopecia,  swollen  glands,  and  sore  throat. 
27 


418       DISEASES   OF   THE   SKIN    AND   ITS   APPENDAGES. 

Erythema  Multiforme  may  manifest  itself  as  a  macular 
eruption,  but  the  macules  are  usually  associated  with  dark-red 
papules  or  tubercles.  The  multiformity  of  the  lesions ;  their 
preference  for  the  extremities  ;  their  appearance  in  successive 
crops ;  the  short  duration  of  each  lesion  ;  the  absence  of  sub- 
jective phenomena,  such  as  itching  and  burning ;  and  the 
presence  of  I'heumatic  pains  are  the  diagnostic  features. 

Pityriasis  rosea. — The  eruption  is  especially  found  on  the 
trunk  ;  the  lesions  are  rose-red  in  color ;  they  are  slightly 
scaly,  the  scales  being  dry  ;  subjective  phenomena  are  gener- 
ally absent ;  and  the  duration  is  a  few  weeks. 

Pediculosis  Corporis. — Lice  may  produce  a  minute  red  or 
pui'ple  eruption.  The  small  size  of  the  lesions  ;  their  confine- 
ment to  the  covered  parts  ;  the  intense  itching  and  the  presence 
of  scratch-marks ;  and  the  discovery  of  pediculi  on  the  clothes 
are  the  diagnostic  features. 

Rbtheln. — This  aflPection  produces  a  macular  or  maculo- 
papular  rash  which  disappears  in  two  or  three  days  by  slight 
desquamation.  The  moderate  fever,  sore  throat,  swollen 
cervical  glands,  and  history  of  contagion  will  assist  in  the 
diagnosis. 

Accidental  Rashes. — Local  inflammation  like  tonsillitis  and 
acute  gastritis,  and  certain  drugs  aud  foods  occasionally  pro- 
duce a  macular  rash. 

Purjmric  spots,  or  hemorrliagiG  macules  (petechiee),  result 
from  minute  extravasation  of  blood  into  the  skin. 

A  purpuric  eruption  is  observed  in  the  following  condi- 
tions : — 

Purpura  Hsemorrhagica  {Morbus  Mamlosus  Werlhofii). — 
This  affection  occurs  especially  in  children  ;  it  is  associated 
with  fever  aud  bleeding  from  the  mucous  membranes ;  and 
generally  runs  a  course  of  one  or  two  weeks. 

Scurvy. — This  disease  results  from  a  deprivation  of  fresh 
vegetables,  and  is  associated  with  spongy,  bleeding  gums, 
great  weakness,  and  a  brawny  induration  of  the  muscles. 

Rheumatism. — Occasionally  an  eruption  of  purpuric  spots 
appears  in  rheumatic  subjects.  It  is  usually  associated  with 
pains  in  the  limbs,  but  fever  is  generally  absent. 


CUTANEOUS   ERUPTIONS.  419 

Peliosis  Rheumatica  {Schonlem's  Disease). — This  is  an  acute 
affection  characterized  by  purpuric  spots,  urticaria,  sore  throat, 
moderate  fever,  and  an  inflammation  of  the  joints  resembling 
rheumatism.  By  some  the  disease  is  regarded  as  a  manifesta- 
tion of  rheumatism. 

Extreme  Anaemia. — A  petechial  rash  is  not  uncommon  in 
pernicious  aneemia,  leucocythsemia,  cancer,  and  advanced 
Bright's  disease.  The  history  and  the  associated  symptoms  of 
the  original  disease  will  indicate  the  diagnosis. 

Certain  Infectious  Diseases, — In  typhus  fever  a  purpuric 
eruption  appears  on  the  fourth  or  fifth  day.  In  cerebro- 
spinal meningitis  the  eruption  is  frequently  petechial.  In 
malignant  measles  and  malignant  smallpox  the  rash  is  often 
hemorrhagic.  In  acute  yellow  atrophy  of  the  liver  and  in 
ulcerative  endocarditis  a  petechial  eruption  is.  frequently 
observed. 

Poisoning  from  Certain  Substances. — Poisoning  from  phos- 
phorus, the  virus  of  venomous  snakes,  mercury,  and  antipyrin 
may  be  associated  with  an  eruption  of  purpura. 

Pediculosis  and  Kindred  Affections. — Body-lice,  bed-bugs, 
and  fleas  produce  petechial  lesions  which  are  surrounded  by 
slight  areolae.  The  itching,  scratch-marks,  and  discovery  of 
the  parasite  are  the  diagnostic  features. 

Brotmi  macules  are  observed  in  : — 

Lentigo,  or  Freckle. — The  spots  are  small,  and  are  found 
esj)ecially  on  exposed  parts — face,  neck,  shoulders,  and  hands. 

Chloasma. — Dark  spots  may  result  from  irritation  of  the 
skin  from  the  action  of  chemicals,  heat,  scratches,  or  blisters. 
They  are  sometimes  noted  in  general  diseases  like  Addison's 
disease  and  syphilis.  They  also  occur  in  primary  affections 
of  the  skin,  as  vitiligo,  morphoea,  scleroderma,  and  leprosy. 

Moles,  or  Wsevus  Pigmentosa. — These  consist  in  congenital 
deposits  of  pigment  on  various  parts  of  the  body. 

White  or  pale  yellow  macules  are  observed  in  :- — • 

Vitiligo. — Apart  from  the  absence  of  pigment,  the  skin  is 
normal  in  appearance  and  function.  An  excess  of  pigment  is 
generally  noted  at  the  periphery  of  the  white  patches. 

Leprosy. — In  this  condition  there  are  structural  changes  in 
the  skin  and  anaesthesia  in  addition  to  the  white  appearance. 


420       DISEASES   OF   THE  SKIN  AND  ITS  APPENDAGES. 

IKEorphoBa. — In  the  late  stage  of  this  affection  the  circum- 
scribed patches  are  white  or  yellow.  The  structure  of  the 
skin  is  altered,  and  the  periphery  of  the  patches  is  distinctly 
hypersemic. 

Facial  Hemiatropliy. — The  onset  of  this  disease  may  be 
marked  by  the  appearance  of  a  yellow  or  white  spot  on  one 
side  of  the  face. 

Diffuse  Erythema  or  Inflammation  of  the  Skin. 

Diffuse  erythema  or  inflammation  of  the  skin  may  result 
from  : — 

The  Action  of  Certain  Drugs  {Dermatitis  Medicamentosa). — 
Belladonna,  quinine,  chloral,  cubebs,  salicylic  acid,  and  arsenic 
may  produce  a  diffuse  red  rash. 

Scarlet  Fever,— The  history  of  contagion,  high  fever,  sore 
throat,  swollen  glands,  rapid  pulse,  and  the  punctiform  charac- 
ter of  the  rash  will  indicate  the  diagnosis. 

Rotheln, — In  some  cases  of  rotheln  the  eruption  is  red  and 
diffuse.  The  history,  slight  fever,  slight  catarrh,  and  marked 
swelling  of  the  post-cervical  glands  will  suggest  rotheln. 

Local  irritation  from  traumatism,  excessive  heat,  poisonous 
plants  or  drugs. 

Erythema  Intertrigo. — This  occurs  where  two  cutaneous 
surfaces  come  in  contact.  The  part  is  red,  moist,  and  some- 
times macerated.     The  condition  excites  a  burning  pain. 

Eczema. — The  skin  is  thickened  aud  infiltrated ;  there  is 
marked  itching ;  the  redness  shades  off  gradually  ;  aud  there  is 
no  fever. 

Erysipelas. — The  part  is  considerably  swollen  ;  the  redness 
aud  swelling  terminate  in  an  abrupt  ridge  ;  and  the  tempera- 
ture is  high. 

Acne  Rosacea. — This  is  a  chronic  disease ;  the  redness 
appears  on  the  face,  and  is  associated  with  acne  lesions  and 
dilated  capillaries. 

Vesicles. 

A  vesicle  is  a  small  elevation  of  the  skin,  containing  serous 
fluid,  and  varying  in  size  from  a  pinhead  to  a  split-pea. 
Vesicles  are  observed  in  the  following  conditions  : — 


CtTTANEOUS   EEUPTIONS.  421 

Sudamen. — This  consists  of  an  eruption  of  minute  vesicles 
which  result  from  the  imprisonment  of  sweat  in  the  layers  of 
the  skin.  It  is  usually  associated  with  free  perspiration  ;  the 
vesicles  are  translucent,  lack  inflammatory  characteristics,  and 
show  no  tendency  to  rupture. 

Herpes. — The  vesicles  appear  in  groups  or  clusters  ;  they 
are  mounted  on  an  inflammatory  base ;  they  show  no  tendency 
to  rupture;  they  are  frequently  associated  with  burning  or 
neuralgic  pains  ;  and  they  are  distributed  along  the  line  of  the 
nerve-trunks. 

Dermatitis  Venanata. —  A  vesicular  eruption  may  result 
from  contact  with  poisonous  plants,  such  as  the  poison  ivy  or 
oak.  The  eruption  generally  appears  on  the  exposed  parts — 
face  or  hands ;  the  part  is  red  and  swollen  and  there  is  intense 
itching. 

Dermatitis  Herpetiformis. — The  vesicles  are  very  irregular 
in  shape  ;  they  appear  in  clusters ;  they  are  very  tense ;  they 
show  no  tendency  to  rupture ;  they  are  frequently  associated 
with  other  lesions — papules,  pustules,  and  bulla ;  they  excite 
intense  itching  ;  and  they  appear  in  crops  over  a  period  of 
weeks  or  months. 

Impetigo  Contagiosa. — The  eruption  consists  of  small  vesi- 
cles which  subsequently  enlarge  until  they  reach  the  size  of 
blebs ;  the  vesicles  appear  iu  crops ;  are  commonly  discrete  ; 
are  flat  and  umbilicated  ;  are  filled  with  a  straw-colored  fluid ; 
they  show  no  tendency  to  break,  but  dry  up  and  form  thin 
yellow  crusts,  and  they  excite  but  little  itching.  The  disease 
is  contagious  and  auto-inoculable ;  occurs  especially  in  chil- 
dren ;  and  lasts  from  one  to  two  weeks. 

Vesicular  Eczema. — The  vesicles  are  quite  small  and  are 
aggregated  in  patches ;  the  intervening  skin  is  red  and  thick- 
ened ;  the  vesicles  tend  to  break  and  pour  forth  a  serous  fluid 
which  keeps  the  part  moist;  and  the  eruption  is  associated 
with  intense  itching. 

Miliaria,  or  Heat-rash. — This  may  appear  as  an  eruption 
of  minute  vesicles  ;  they  are  alway  discrete  ;  they  are  sur- 
rounded by  red  areolae ;  they  usually  appear  on  the  trunk ; 
they  are  generally  associated  with   pin-head   papules  ;   they 


422       DISEASES   OF   THE   SKIN  AND   ITS  APPENDAGES. 

show  no  tendency  to  rupture  ;  and  they  excite  a  little  burning 
and  itching. 

Scabies. — In  this  aiFectiou  the  vesicles  are  small ;  they  are 
usually  associated  with  pustules  and  burroivs;  they  excite  in- 
tense itching ;  and  they  are  usually  found  on  the  hands,  fore- 
arms, in  the  axillae,  under  the  mammae,  and  on  the  inner 
aspects  of  the  thighs. 

Blebs,  or  BiiUje. 

A  bleb,  or  bulla,  is  a  circumscribed  elevation  of  the  skin, 
containing  serous  fluid,  and  varying  in  size  from  a  pea  to  an 
egg.     Blebs  are  observed  in  the  following  conditions  : — 

Impetigo  Contagiosa. — The  blebs  are  flat  and  umbilicated  ; 
they  contain  a  straw-colored  fluid ;  they  appear  in  crops ;  they 
are  commonly  discrete ;  they  show  no  tendency  to  break,  but 
dry  up  and  form  thin  yellow  crusts ;  and  they  excite  but  little 
itching.  The  disease  is  contagious  and  auto-inoculable  ;  occurs 
especially  in  children  ;  and  lasts  from  one  to  two  weeks. 

Dermatitis  Herpetiformis. — The  bulla  are  frequently  asso- 
ciated with  papules,  vesicles,  and  pustules ;  they  are  surrounded 
by  inflamed  skin ;  they  appear  in  clusters ;  they  show  no 
tendency  to  break,  but  dry  up  and  leave  yellowish-bro^Ti 
crusts  ;  and  they  excite  considerable  itching. 

Pemphigus. — The  bullae  appear  in  crops ;  excite  but  little 
itching  ;  they  lack  an  inflammatory  areola  ;  and  as  a  rule  they 
dry  up,  and  leave  behind  a  thin  pellicle.  The  disease  is 
generally  chronic. 

Syphilis. — The  bullous  syphilide  is  observed  in  hereditary 
svphilis,  and  very  late  in  the  acquired  disease.  The  contents 
of  the  bulla  soon  become  pustular;  the  blebs  dry  up,  and 
form  dark-green,  cone-shaped,  stratified  crusts,  which  become 
detached  and  leave  discharging  ulcers.  The  history  and  the 
other  evidences  of  syphilis  will  aid  in  the  diagnosis. 

Pustules. 

A  pustule  is  a  small  circumscribed  elevation  of  the  skin 
containing  pus.  Pustules  are  observed  in  the  following  dis- 
eases : — 


CUTANEOUS   ERUPTIONS.  423 

Eczema  Pustulosum. — The  pustules  are  small;  are  aggre- 
gated in  a  patch ;  are  generally  associated  with  minute 
vesicles ;  the  intervening  skin  is  red  and  thickened ;  and 
there  are  marked  burning  and  itching. 

Acne  Vulgaris, — The  pustules  are  usually  confined  to  the 
face,  back,  and  shoulders ;  they  have  their  origin  in  the 
sebaceous  follicles  ;  they  are  generally  associated  with  papules 
and  comedones ;  and  they  excite  no  itching. 

Dermatitis  Herpetiformis. — The  pustules  are  frequently 
associated  with  papules  and  vesicles  ;  they  are  surrounded  by 
inflamed  skin  ;  they  appear  in  clusters ;  and  they  excite  con- 
siderable itching. 

Impetigo  Simplex. — Tliis  affection. is  usually  observed  in 
children  ;  the  pustules  are  round,  and  range  in  size  from  a 
pea  to  a  cherry  ;  there  is  only  a  slight  red  areola,  and  tliis 
finally  disappears ;  the  pustules  remain  discrete ;  they  sliow 
little  tendency  to  rupture,  but  dry  up  and  form  yellowish- 
brown  crusts ;  they  are  mostly  observed  on  the  extremities ; 
they  excite  no  itching.  The  disease  lasts  from  a  few  days  to 
a  week. 

Impetigo  Contagiosa. — The  eruption  is  at  first  vesicular,  Ijut 
it  soon  becomes  pustular;  the  pustules  vary  iu  size  from  a  pea 
to  a  large  marble ;  they  are  flat  and  umbilicated  ;  they  appear 
in  crops  ;  they  are  commonly  discrete  ;  they  show  no  tendency 
to  break,  but  dry  up  and  form  thin  yellow  crusts ;  and  they 
excite  but  little  itching.  The  disease  is  contagious  and  auto- 
inoculable ;  occurs  especially  in  children  ;  and  lasts  from  one 
to  two  weeks. 

Varicellaj  or  Chicken-pox, — The  pustules  result  from  vesi- 
cles ;  they  appear  especially  on  the  trunk ;  they  are  small  and 
not  umbilicated ;  they  excite  but  little  itching.  There  is  some 
fever.     The  disease  lasts  but  three  or  four  days. 

Ectll3^a. — 'This  disease  is  observed  especially  in  poorly- 
nourished  adults.  The  pustules  vary  in  size  from  a  pea  to  a 
cherry ;  they  are  few  in  number ;  they  are  mounted  on  an 
inflammatory  base,  and  are  surrounded  by  a  distinct  inflam- 
matory areola ;  they  excite  but  little  itching ;  they  seldom 
break,  but  dry  up  and  form  brownish  crusts. 


424       DISEASES   OF   THE  SKIN  AND   ITS  APPENDAGES. 

Smallpox. — In  this  disease  shot-like  papules  and  umbili- 
cated  vesicles  precede  or  are  associated  with  the  pustules.  The 
latter  are  small,  surrounded  by  a  red  areola,  and  usually  excite 
some  itching.  The  high  fever  and  history  of  contagion  will 
assist  in  making  the  diagnosis. 

Syphilis. — The  pustules  are  frequently  associated  with  other 
lesions ;  they  are  often  mounted  on  a  copper-colored  inflamma- 
tory base ;  they  excite  no  itching ;  and  they  are  usually  asso- 
ciated with  the  history  and  the  other  evidences  of  syphilis. 

Scabies. — The  pustules  are  small  and  usually  associated 
with  papules,  vesicles,  and  burrows ;  they  are  especially  ob- 
served on  the  hands,  forearms,  in  the  axillae,  under  the  mam- 
mee,  and  on  the  inner  aspects  of  the  thighs,  and  they  excite 
considerable  itching.     There  is  often  a  history  of  contagion. 

Papules. 

A  papule  is  a  circumscribed  solid  elevation  of  the  skin 
varying  in  size  from  a  pin-head  to  a  xyea.  Papules  are  ob- 
served in  the  following  conditions  :- — 

Er3^1iema  Multiforme. — The  papules  are  often  associated 
with  macules  and  tubercles  ;  they  are  flat,  and  are  of  a  bright- 
red  or  purple  color ;  they  appear  especially  on  the  extremities ; 
and  they  show  no  tendency  to  suppurate,  but  gradually  disap- 
pear in  the  course  of  two  or  three  weeks ;  they  excite .  no 
itching,  but  they  are  bften  associated  with  prostration  and 
rheumatic  pains. 

After  the  Use  of  Certain  Drugs. — Bromides,  iodides, 
copaiba,  cnbebs,  and  tar  may  produce  a  papular  eruption. 
The  history  will  aid  in  the  diagnosis. 

Eczema  Papulosum. — The  papules  are  very  small,  closely 
aggregated,  and  often  associated  with  vesicles  and  pustules ; 
the  skin  is  thickened  ;  and  there  is  intense  itching. 

Miliaria,  or  Prickly  Heat. — The  papules  are  very  small ; 
they  are  very  often  associated  with  minute  vesicles;  they 
always  remain  discrete ;  they  appear  especially  on  the  trunk  ; 
and  they  excite  a  little  burning  and  itching. 

Acne  Vulgaris. — The  papules  are  usually  confined  to  the 
face,  backj  and  shoulders;  they  are  generally  associated  with 


CUTANEOUS  ERUPTIONS.  425 

pustules  and  comedones ;  thej  involve  the  sebaceous  follicles ; 
and  they  do  not  excite  subjective  symptoms. 

Scabies. — The  papules  are  small  and  are  usually  associated 
with  pustules,  vesicles,  and  burrows ;  they  are  especially  ob- 
served on  the  hands,  forearms,  in  the  axillae,  under  the  mam- 
mae, and  on  the  inner  aspects  of  the  thighs ;  and  they  excite 
considerable  itching.     There  is  often  a  history  of  contagion. 

Syphilis. — The  papules  are  dark  in  color ;  they  are  widely 
distributed,  being  especially  marked  on  the  trunk  and  flexor 
surfaces  of  the  extremities ;  they  are  usually  associated  with 
pustules;  and  they  excite  no  itching.  The  history  and  the 
accompanying  evidences  of  syphilis  will  aid  materially  in 
establishing  the  diagnosis. 

Smallpox. — The  papules  are  hard  and  have  a  shot-like  feel ; 
they  soon  terminate  in  umbilicated  vesicles ;  they  excite  some 
itching,  and  they  are  associated  with  high  fever,  pain  in  the 
back,  and  often  a  history  of  contagion. 

Measles. — The  papules  are  small,  and  run  together  to  form 
crescentic-shaped  patches ;  and  they  are  associated  with  mod- 
erate fever,  swollen  cervical  glands,  coryza,  conjunctivitis,  and 
bronchitis.     There  is  often  a  history  of  contagion. 

Tubercles. 

Tubercles  are  large,  circumscribed,  solid  elevations  of  the 
skin  varying  in  size  from  a  large  pea  to  a  walnut.  They  are 
observed  in  the  following  conditions : — 

Erythema  Nodosum. — The  tubercles  are  large ;  they  usually 
appear  on  the  extremities  ;  they  are  reddish-purple  in  color ; 
they  never  suppurate ;  and  they  are  associated  with  malaise, 
fever,  and  rheumatic  pains. 

Erythema  Multiforme. — The  tubercles  are  generally  asso- 
ciated with  macules  and  papules ;  they  are  flat,  and  are  of  a 
bright-red  or  purple  color ;  they  appear  especially  on  the  ex- 
tremities, and  they  show  no  tendency  to  suppurate,  but  gradu- 
ally disappear  in  the  course  of  two  or  three  weeks.  They 
excite  no  itching,  but  are  often  associated  with  prostration  and 
rheumatic  pains.  The  disease  is  probably  allied  to  erythema 
nodosum- 


426       DISEASES   OF  THE   SKIN   AND   ITS   APPENDAGES. 

Lupus  Vulgaris. — This  may  begin  as  a  papule  or  tubercle. 
It  is  especially  observed  on  the  face.  The  tubercles  are  of  a 
pale-red  color  and  are  quite  soft  to  the  touch.  As  a  rule, 
they  slowly  break  down  and  form  shallow  ulcers  with  soft  red 
margins.  The  ulcers  are  painless  and  secrete  but  little  ma- 
terial. They  may  invade  all  of  the  soft  structures,  but  the 
bones  escape. 

Syphilis. — The  tubercular  syphilide  manifests  itself  as  dark- 
red  tubercles.  There  are  seldom  more  than  three  or  four,  and 
they  generally  appear  on  the  face  and  extremities.  They  are 
very  firm,  and  often  break  down,  forming  deep,  punched-out 
ulcers  which  secrete  an  abundant  purulent  material. 

Tinea  Sycosis,  or  Barber's  Itoli. — The  tubercles  appear  on 
the  hairy  parts  of  the  face  and  involve  the  hair-follicles.  Sup- 
puration soon  begins  in  the  centre  of  the  tubercles,  and  the 
hairs  become  dry,  brittle,  and  loose.  The  microscope  will  re- 
veal the  tricophyton. 

Leprosy. — One  form  of  leprosy  manifests  itself  as  tubercles. 
The  latter  are  of  a  pale-red  or  yellow  color,  and  undergo  slow 
absorption  or  ulceration.  There  is  usually  more  or  less  anaes- 
thesia in  the  parts  affected. 

Wheals,  or  Pomphi. 

Wheals  are  evanescent  elevations  of  the  skin,  generally 
more  or  less  round,  and  often  white  in  the  centre  and  pale-red 
at  the  periphery.  They  excite  considerable  itching.  They 
are  observed  in  the  following  conditions  : — 

Urticaria. — The  wheals  appear  in  crops  ;  they  are  of  very 
short  duration;  they  may  appear  on  any  part  of  the  body  ; 
and  they  excite  intense  itching. 

Erythema  multiforme,  peliosis  rheumatica  (Schonlein's  dis- 
ease), and  certain  insects  like  mosquitoes  also  produce  wheals. 

Crusts. 

Crusts  consist  in  dried  exudation,  and  may  be  red,  yellow, 
brown,  or  green  in  color.  They  are  marked  in  the  following 
diseases : — 


CUTANEOUS   ERUPTIONS.  427 

Eczema. — The  crusts  are  generally  associated  with  pustules 
and  vesicles;  the' surrounding  skin  is  red  and  thickened  ;  and 
there  is  considerable  itching. 

Seborrhoea. — Crusts  of  seborrhoea  are  generally  observed 
on  the  scalp.  Itching  is  absent,  and  there  are  no  evidences  of 
inflammation. 

Syphilis. — The  crusts  are  thick ;  they  are  of  a  dark-brown 
or  green  color ;  and  they  are  often  associated  with  ulcers 
which  freely  discharge.  The  history  and  other  evidences  of 
syphilis  will  aid  in  the  diagnosis. 

Impetigo. — The  crusts  are  thin  and  yellow ;  and  they  are 
associated  with  blebs  which  appear  in  crops. 

Favus. — The  crusts  generally  appear  on  the  scalp  ;  they  are 
yellow,  brittle,  and  cup-shaped ;  they  are  usually  perforated 
by  a  hair,  and  have  a  peculiar  musty  odor. 

Tinea  Tonsurans,  or  Ringworm  of  the  Scalp. — In  neglected 
cases  this  affection  may  be  associated  with  crusting.  It  is 
only  observed  in  children.  The  grayish  scales,  the  dry,  brittle, 
and  broken  hairs  projecting  through  the  crusts,  the  alopecia, 
and  the  detection  of  the  tricophyton  are  the  diagnostic 
features. 

Scales. 

Scales  are  dry  exfoliations  from  the  upper  layers  of  the  skin. 
They  are  observed  in  the  following  diseases  : — 

Squamous  Eczema. — The  scales  are  usually  associated  with 
papules ;  the  underlying  skin  is  red  and  thickened ;  and  there 
is  often  marked  itching. 

Seborrhoea  Sicca. — The  scales  are  greasy,  and  the  under- 
lying skin  shows  no  evidence  of  inflammation.  The  sebaceous 
follicles  are  often  dilated. 

Psoriasis. — The  scales  are  dry,  and  are  of  a  pearly- white 
color  ;  they  are  associated  with  circumscribed,  sharply-defined, 
elevated  inflammatory  patches.  The  extensor  surfaces  are 
especially  involved.     There  is  little  or  no  itching. 

Ichthyosis. — This  affection  begins  in  early  life.  The  scales 
are  dry,  and  are  especially  marked  on  the  extensor  surfaces. 
Itching  is  absent,  and  there  is  no  evidence  of  inflammation. 


428       DISEASES  OF  THE  SKIN  AND  ITS   APPENDAGES. 

Syphilis. — The  scales  are  dry,  and  are  of  a  grayish  color ; 
they  are  usually  associated  with  papules ;  and  they  are  espe- 
cially marked  on  the  palms  and  soles.  There  is  no  itching. 
The  history  and  other  evidences  of  syphilis  will  assist  in  the 
diagnosis. 

Pit3ririasis  Rosea, — The  scales  are  found  especially  on  the 
trunk,  and  are  associated  with  small,  rose-red  macules.  There 
is  no  itching.  The  disease  runs  an  acute  course  of  a  few  weeks' 
duration. 

Ringworm. — The  scales  are  dry  and  scant ;  they  are  associ- 
ated with  circumscribed  red  patches  which  tend  to  disappear 
in  the  centre.  There  is  often  marked  itching.  Microscopic 
examination  reveals  the  tricophyton. 

Ulcers. 

Ulcers  are  observed  especially  in  the  following  diseases  : — • 

Syphilis. — The  ulcers  are  deep ;  they  have  a  punched-ont 
appearance ;  they  secrete  an  abundant  offensive  material ;  they 
often  involve  the  bone ;  they  extend  rapidly ;  they  are  not 
painful,  and  the  imperfect  cicatrix  which  they  produce  is  soft. 
The  history  and  other  evidences  of  syphilis  will  aid  in  the 
diagnosis. 

Epithelioma. — This  appears  in  late  life ;  there  is  usually  a 
single  centre  of  ulceration  ;  the  ulcer  is  irregular  in  shape ; 
the  edges  are  thickened  and  infiltrated ;  the  secretion  is  scanty 
and  bloody ;  the  progress  is  somewhat  slow,  and  there  is  often 
pain. 

Lupus  Vulgaris. — This  generally  appears  in  early  life ;  there 
are  often  several  centres  of  ulceration ;  the  ulcers  are  usually 
superficial ;  the  edges  are  not  thickened ;  the  progress  is  ex- 
tremely slow;  the  bones  are  never  involved;  there  is  very 
little  secretion,  and  soft  papules  often  develop  in  the  cicatrix, 
which  is  firm  and  contracted. 

Simple  Ulcers  may  result  from  traumatism,  the  application 
of  caustics,  or  the  action  of  intense  heat  or  cold.  Ulcers  are 
frequently  observed  on  the  legs  of  old  people  in  association 
with  varicose  veins.  Simple  ulcers  may  be  recognized  by  the 
history,  location,  appearance,  and  the  absence  of  other  causes. 


CUTANEOUS  ERUPTIONS.  429 

Perforating  Ulcer  of  the  Foot. — This  term  is  applied  to  a 
deep-seated  ulcer  appearing  on  the  sole  of  the  foot  and  most 
frequently  observed  in  locomotor  ataxia.  It  usually  begins  as 
a  corn  in  the  neighborhood  of  the  great  toe,  and  is  generally 
associated  with  anaesthesia  of  the  sole  of  the  foot. 

Decubitus. — This  term  is  applied  to  the  bedsores  which 
form  after  the  occurrence  of  grave  cerebral  or  spinal  lesions. 
They  are  generally  observed  on  parts  which  are  subjected  to 
pressure,  as  the  sacrum,  buttocks,  calves,  and  heels,  and  are 
preceded  by  erythema  and  vesication. 


430       DISEASES  OF  THE  SKIN   AND  ITS   APPENDAGES. 

DISEASES  OF  THE  SWEAT-GLANDS. 

Anidrosis. 

Definition. — A  deficiency  of  sweat. 

Etiology. — It  may  })e  a  symptom  of  some  general  disease, 
like  diabetes  or  Bright's  disease  ;  it  may  be  an  associated  con- 
dition in  certain  cutaneous  diseases,  such  as  ichthyosis  or  psori- 
asis ;  and  it  may  develop  without  obvious  exciting  cause  as  a 
result  of  disturbed  innervation. 

Treatment. — Remedies  should  be  directed  to  the  primary 
disease. 

Hyperidi'osis. 

Definition. — Excessive  sweating. 

Etiology. — As  a  general  condition  it  is  often  observed  in 
phthisis  and  in  other  diseases  characterized  by  marked  de- 
bility. Local  hyperidrosis  is  most  frequently  observed  in  the 
hands,  feet,  and  axillae,  and  probably  results  from  some  de- 
rangement of  the  sympathetic  nervous  system.  Unilateral 
sweating  of  the  face  may  indicate  an  aneurism  or  tumor 
pressing  on  the  cervical  sympathetic. 

Symptoms. — The  primary  symptom  is  excessive  sweating, 
and  this  often  leads  to  intertrigo  or  eczema.  Bromidrosis  is 
often  associated  with  the  hyperidrosis. 

Prognosis. — Guarded.  In  many  cases  the  condition  is 
very  obstinate. 

Treatment. — Frequently  there  is  an  evident  impairment 
of  the  general  health  which  will  require  appropriate  treat- 
ment. Internally,  one  of  the  following  remedies  may  be  em- 
ployed to  diminish  the  amount  of  sweat :  Belladonna,  picro- 
toxin,  agaricin,  or  ergot. 

Loeal  Treatment — Dusting-powders  of  starch,  talc,  or  lyco- 
podium  with  boric  or  salicylic  acid ;  or  lotions  containing 
sulphate  of  zinc,  tannic  acid,  or  alum,  are  often  very  useful. 

'^i  Pulv.  acid,  salicylic, 
Pnlv.  zinci  carb.  prgecip., 
Pulv.  magnesii  ustse,  aa  giv  ; 
Pulv.  amyli,  ^xv ; 

Pulv.  talci,  3XX.— M.     (Hard  A  WAY.) 
Sig.  — Dusting-powder. 


DISEASES   OF  THE  SWEAT-GLANDS.  431 

In  hyperidrosis  of  the  feet  the  method  suggested  by  Hebra 
is  often  very  efficient.  The  feet  should  be  washed,  thoroughly 
dried,  and  then  carefully  enveloped  in  strips  of  musliu  which 
have  been  spread  with  diachylon  ointment.  The  application 
should  be  made  twice  daily.  In  the  dressing  no  water  should 
be  employed,  but  the  feet  must  be  carefully  wiped  and  then 
dusted  with  starch  or  lycopodium  before  the  ointment  is  re- 
applied. The  treatment  should  be  continued  for  from  one  to 
two  weeks,  after  which  the  feet  may  be  washed  and  the  dust- 
ing-powder alone  used 

Bromitlrosis. 

(Osmidrosis.) 

Definition. — A  functional  affection  characterized  by  the 
excretion  of  sweat  Avhich  has  a  fetid  odor. 

Symptoms. — It  is  generally  local  and  often  confined  to  the 
feet ;  it  is  frequently  associated  with  hyperidrosis. 

Tkeatment. — Same  as  hyperidrosis. 

Chromidi'osis. 

Definition. — A  functional  affection  characterized  by  the 
secretion  of  colored  sweat. 

Symptoms. — The  parts  most  frequently  affected  are  the  face 
and  trunk ;  the  most  common  colors  are  red  and  yellow.  It 
is  often  associated  with  hyperidrosis. 

Sudamen. 

Definition. — A  cutaneous  affection  characterized  by  the 
eruption  of  minute  vesicles  resulting  from  the  retention  of 
sweat  in  the  layers  of  the  skin. 

Etiology. — It  is  often  observed  in  health  in  persons  who 
perspire  freely.  It  is  frequently  noted  in  febrile  diseases 
which  are  associated  with  sweating,  like  pneumonia  and 
typhoid  fever. 

Symptoms. — Minute,  irregular,  translucent  vesicles  appear 
on  the  surface.     They  are  not  surrounded  by  an  inflammatory 


432       DISEASES  OF  THE  SKIN   AND   ITS   APPENDAGES. 

areola.     They  do  not  rupture,  but  dry  up  and  are  followed  by 
slight  desquamation. 

Treatment. — The  affection  has  little  significance  and  treat- 
ment is  rarely  required. 

FimCTIONAIi  DISEASES  OF  THE  SEBACEOUS 
GLANDS. 

Seborrhcea. 

(SteorrhcBa.) 

Definition. — A  functional  affection  characterized  by  ex- 
cessive secretion  of  sebaceous  material  which  may  be  normal 
or  perverted. 

Etiology. — In  many  cases  the  cause  is  not  apparent. 
Often  the  disease  is  associated  with  impairment  of  the  general 
health.     By  some  it  is  regarded  as  of  parasitic  origin. 

Varieties. — Seborrhcea  sicca  and  seborrhoea  oleosa. 

Seborrhcea  Sicca. — This  form  is  most  frequently  observed 
on  the  scalp  and  constitutes  what  is  popularly  termed  dan- 
druff. Examination  reveals  an  incrustation  composed  of  thin, 
yellowish-gray,  greasy  scales.  In  uncomplicated  cases  the 
skin  is  pale,  but  from  irritation  it  may  subsequently  become 
hypersemic  or  inflamed.  When  allowed  to  continue,  the 
nutrition  of  the  hair  is  interfered  with  and  baldness  results. 

On  the  body  seborrhoea  sicca  appears  as  yellowish-gray 
slightly  elevated  patches  covered  with  greasy  scales.  The  out- 
lets of  the  follicles  are  often  dilated.  There  is  generally  more 
or  less  redness  of  the  skin  from  hypersemia  {sehorrhceal  eczema.) 

Seborrhoea  Oleosa. — This  form  is  most  commonly  observed 
on  the  face,  particularly  about  the  nose,  which  is  habitually 
bathed  in  an  oleaginous  material  which  has  exuded  from  the 
sebaceous  follicles.  From  irritation  the  parts  are  often  red. 
The  condition  is  frequently  associated  with  seborrhoea  sicca, 
comedo,  and  acne. 

Diagnosis.  Eczema, — In  this  disease  the  skin  is  red  and 
thickened ;  there  is  marked  itching ;  and  the  scales  are  not 
greasy. 


COMEDO.  433 

Psoriasis. — In  this  disease  the  scales  are  dry  and  pearly  and 
there  are  evidences  of  inflammation. 

Prognosis. — Favorable  under  prolonged  and  judicious 
treatment. 

Treatment — The  general  health  may  be  impaired  ;  hence 
tonics  like  iron,  strychnine,  and  cod-liver  oil  are  often  indi- 
cated. The  gastro-intestinal  tract  will  often  require  especial 
attention.  Constipation  should  be  relieved  by  diet,  enemata, 
or  mild  laxatives. 

Local  Treatment — Crusts  should  be  removed  by  applications 
of  oil,  followed  by  shampooing  with  alcohol  and  green  soap. 
When  the  scalp  is  thoroughly  clean,  one  of  the  following 
remedies  may  be  applied  :  Sulphur,  mercury,  tar,  carbolic  acid, 
or  resorcin. 

^  Sulphur,  loti,  gij  ; 

Balsami  Peruvian!,  ^ss ; 
Vaselini,  ^x.— M.     (G.  H.  Fox.) 
Sig. — After  bathing  the  part  apply  the  ointment. 

Or— 

^  Acid,  carbolic,  ITtxxx  ; 
Olei  ricini,  f  .^ij  ; 
Alcoholis,  f  3j-3yi.— M. 

(DuHRiNG  and  Stel wagon.  ) 
Sig. — Fill  an  eye-dropper,  introduce  between  the  hairs,  and  sub- 
sequently rub  in  by  means  of  a  flannel  rag. 

Mild  cases  of  facial  seborrhoea  often  yield  to  the  following 
ointment : — 

^  Hydrarg.  chlor.  mit.,  gr.  xx; 
Ung.  zinc,  oxid.,  5j. — M. 
Sig. — Apply  at  bedtime. 

Comedo. 

Definition. — A  functional  disease  of  the  sebaceous  glands, 
characterized  by  the  retention  of  discolored  sebaceous  material 
in  the  distended  ducts  of  the  gland. 

Etiology. — It  is  most  frequently  observed  in  young  adults. 
Debility,    gastro-intestinal    disorders,   anaemia,    and   lack   of 
cleanliness  are  predisposing  factors. 
28 


434       DISEASES   OF  THE  SKIN   AND  ITS  APPENDAGES. 

Pathology. — The  material  in  the  ducts  is  composed  of 
sebum,  altered  epithelium,  and  pigment  matter  which  is  prob- 
ably derived  from  without.  Microscopic  examination  of  the 
material  often  reveals  a  mite — the  demodex  foUiculorum — but 
its  presence  is  accidental  and  of  no  etiological  significance. 
Comedo  is  generally  associated  with  seborrhoea. 

Symptoms. — The  disease  is  characterized  by  an  aggregation 
of  minute  black  or  yellowish  spots  which  correspond  to  the 
outlets  of  the  sebaceous  glands.  The  lesion  is  often  slightly 
elevated,  and  when  the  skin  is  squeezed  a  white  filiform  mass 
exudes,  to  which  the  term  "  flesh-worm"  has  been  popularly 
applied.  The  parts  most  commonly  aifected  are  the  face,  back, 
and  ears.  The  condition  frequently  excites  an  inflammation 
of  the  follicles,  hence  it  is  often  associated  with  acne. 

Prognosis.  —  Favorable  under  persistent  and  judicious 
treatment. 

Treatment. — Ansemia,  dyspepsia,  and  constipation  must 
be  treated  by  a  careful  regulation  of  the  personal  hygiene,  and 
by  the  use  of  appropriate  remedies.  Tonics  like  iron,  quinine, 
cod-liver  oil,  and  strychnine  are  often  indicated. 

Local  Treatment.  —  Large  pings  may  be  pressed  out  by 
means  of  a  watch-key  or  a  special  instrument  for  the  purpose. 
Softening  and  removal  of  smaller  plugs  may  be  hastened  by 
the  application  of  cloths  wrnng  out  in  very  hot  water.  Kneed- 
ing  and  the  application  of  alcohol  and  green  soap  will  also 
assist  in  their  expulsion.  Mercury  and  sulphur  are  useful 
remedies. 

^   Hydrarg.  chlor.  corros.,  gr.  iv  ; 
Alcohoiis,  f  Jj  ; 

Aquse  I'osje,  q.  s.  ad  fgiv.— M. 
Sig. — Dab  on  twice  daily. 

Milium. 

(Grutum.) 

Definition. — An  affection  characterized  by  the  appearance 
of  small,  pearly,  non-inflammatory  elevations,  which  result 
from  the  accumulation  of  inspissated  sebum  in  ducts,  the  out- 
lets of  which  have  been  occluded. 


STEATOMA — ^ERYTHEMA   SIMPLEX.  435 

Symptoms. — It  is  generally  observed  about  the  face,  and 
consists  of  a  collection  of  small,  round,  pearly  elevations,  which 
vary  in  size  from  a  pin-head  to  a  small  pea.  The  contents  of 
the  distended  duct  cannot  be  squeezed  out  until  an  opening  is 
made,  and  thus  it  diifers  from  comedo.  It  is  frequently  asso- 
ciated with  comedo  and  acne. 

Treatment. — Incise  the  lesion,  express  the  contents,  and 
treat  as  in  seborrhoea. 

Steatoma. 

("Wen.) 

Definition. — A  steatoma,  or  wen,  is  a  cyst  resulting  from 
the  retention  of  secretion  in  a  sebaceous  gland. 

Symptoms. — One  or  more  rounded  or  oval  elevations,  vary- 
ing in  size  from  a  pea  to  a  large  walnut,  slowly  appear  on  the 
scalp,  face,  or  back.  They  are  painless,  rather  soft,  and  when 
opened  are  found  to  contain  a  yellowish-white  caseous  mass. 

Diagnosis.  Fatty  Tumors. — Fatty  tumors  are  rare  on  the 
scalp ;  they  are  frequently  lobulated ;  they  have  a  doughy 
feel ;  and  are  not  so  movable  as  wens. 

Treatment. — The  sack  and  its  contents  should  be  carefully 
dissected  out.  Simple  excision  and  evacuation  are  always  fol- 
lowed by  a  return  of  the  cyst. 

ERYTHEMA  SIMPLEX. 

Definition. — Active  hypersemia  of  the  skin. 

Etiology. — It  may  result  from  exposure  to  heat  or  cold ; 
from  traumatism  ;  or  from  the  application  of  some  irritating 
substance.  A  symptomatic  variety  is  frequently  observed  in 
gastric  irritation  and  systemic  diseases. 

Symptoms. — Diffuse  uniform  redness,  disappearing  on  pres- 
sure, and  without  thickening  or  elevation  of  the  skin.  When 
it  is  marked,  there  may  be  slight  burning. 

Treatment. — Sedative  lotions  or  dusting-powders. 


436       DISEASES   OF   THE  SKIN  AND   ITS  APPENDAGES. 

ERYTHEMA  EVTERTRIGO. 

(Chafing.) 

Definition. — Hypersemia  induced  by  the  attrition  of  op- 
posing surfaces  of  the  skin. 

Etiology. — It  is  common  in  children  and  in  fat  subjects. 
It  is  especially  noted  where  there  are  friction  and  perspiration, 
as  under  pendulous  mammse,  between  the  upper  parts  of  the 
thighs,  and  around  the  genitalia. 

Symptoms. — It  is  characterized  by  diffuse  redness,  and 
often  by  heat  and  moisture.  It  excites  a  burning  sensation. 
When  the  cause  is  continued  it  may  result  in  dermatitis. 

Teeatment. — Apply  a  lotion  of  boric  acid  and  follow  with 
a  dusting-powder. 

ERYTHEMA  NODOSUM. 

(Dermatitis  Contusiformis.) 

Definition. — An  acute  inflammatory  disease,  characterized 
by  crops  of  large  bright- red  nodes  which  in  the  process  of  evo- 
lution assume  different  colors  as  in  the  fading  of  a  bruise. 

Etiology. — Unknown 

Symptoms. — There  is  a  sudden  eruption  of  bright-red 
nodes  varying  in  size  from  a  pea  to  an  egg.  The  extremities 
are  most  commonly  affected.  The  advent  is  marked  by 
malaise,  headache,  slight  fever,  and  rheumatoid  pains.  At 
first  the  lesions  resemble  boils,  but  unlike  the  latter,  they  do 
not  suppurate,  but  gradually  turn  yellow,  blue,  and  green  as  a 
bruise. 

Prognosis. — Favorable.     Duration  a  few  weeks. 

Treatment. — Iodide  of  potassium  and  alkalies  have  been 
recommended.  Locally,  lead-water  and  laudanum  make  a 
soothing  application. 

ERYTHEMA  MUETIFORIVIE. 

Definition. — An  inflammatory  disease  characterized  by 
erythematous,  papular,  vesicular,  or  bullous  lesions. 


URTICARIA.  437 

Etiology. — It  is  more  common  in  women  than  in  men. 
It  is  apt  to  develop  in  the  spring  or  fall.  Rheumatism  and 
gastro-intestinal  disturbances  seem  to  predispose. 

Symptoms. — It  is  marked  by  an  eruption,  usually  on  the 
extremities,  of  the  following  lesions  :  macules,  papules,  vesicles, 
or  bullffi.  The  lesions  may  aggregate  or  remain  discrete  ;  they 
last  one  or  two  weeks  and  gradually  fade.  There  is  little  or 
no  itching.  In  some  cases  there  is  decided  constitutional  dis- 
turbance, manifested  by  malaise,  headache,  slight  fever,  and 
rheumatic  pains. 

Diagnosis.  Det-matitis  Herpetiformis.  —  The  marked 
itching,  the  greater  tendency  for  the  lesions  to  cluster,  and  the 
chronic  character  of  dermatitis  herpetiformis  will  usually  pre- 
vent an  error  in  diagnosis. 

Urticaria. — In  this  disease  the  individual  lesions  last  a  very 
short  time  and  are  associated  with  marked  itching. 

PEOGNOSis.^Favorable.     Duration  a  few  weeks. 

Treatment. — In  the  debilitated  iron  and  quinine  are  useful. 
In  the  rheumatic,  the  salts  of  lithium  and  of  potassium  may 
be  employed.  Constipation  should  be  relieved  by  saline  laxa- 
tives. Locally,  lotions  of  boric  or  carbolic  acid  followed  by 
dusting-powders  exert  a  beneficial  effect. 

URTICARIA. 

(Hives,  Nettle  Rash.) 

Definition. — An  inflammatory  affection  characterized  by 
the  eruption  of  pale-red,  evanescent  wheals  which  are  asso- 
ciated with  severe  itching. 

Etiology. —  Gastro-intestinal  disturbances,  emotional  ex- 
citement, and  chronic  visceral  diseases  predispose.  In  some 
it  may  be  excited  by  certain  articles  of  food  such  as  shell- 
fish, strawberries,  etc.  The  bites  of  certain  insects  produce  the 
disease,  such  as  mosquitoes,  bed-bugs,  and  caterpillars.  Some 
drugs  induce  urticaria  in  susceptible  people. 

Pathology. — The  disease  consists  in  a  vaso-motor  spasm, 
followed  by  paresis  of  the  vessels  and  an  outpouring  of  serum. 

Symptoms. — There  is  a  sudden  general  eruption  of  papules 
or   wheals  which   is  associated   with  intense  itching.     Each 


438       DISEASES  OF  THE  SKIN  AND  ITS  APPENDAGES. 

lesion  lasts  a  few  hours  and  is  succeeded  by  new  ones  in  other 
places. 

Varieties.  Urticaria  Papulosa. — In  this  form  the  wheal 
is  followed  by  a  lingering  papule  which  is  attended  by  consid- 
erable itching.  It  is  most  commonly  observed  in  debilitated 
children. 

Urticaria  Hemorrhagica. — The  lesions  are  infiltrated  with 
blood. 

Diagnosis.  Erythema  Multiforme  and  Erythema  Nodo- 
sum.— In  both  of  these  affections  the  lesions  last  much 
longer,  and  are  free  from  itching. 

Prognosis.  —  Unfavorable.  In  some  cases  it  tends  to 
become  chronic. 

Treatment. — The  cause  should  be  removed  when  possible. 
In  gastric  irritation  bismuth,  or  calomel  and  soda  are  useful. 

When  there  is  constipation  a  saline  laxative  may  prove  very 
efficient.  The  special  remedies  usually  recommended  are  alka- 
lies, salicylate  of  sodium,  quinine,  iodide  of  potassium,  and 
atropine. 

Locally,  lotions  of  water  and  alcohol,  carbolic  acid,  boric 
acid,  or  hydrocyanic  acid  are  very  useful : 

^  Acid,  carbolic,  Sj-^ij  ; 
Glycerini,    f|ss  ; 
Alcohol.,  f^vj  ; 
Aquae,  q.  s.  ad  Oj. — M. 

Urticaria  Pigmentosa. 

This  is  a  form  of  urticaria  observed  in  young  children.  It 
is  characterized  by  an  eruption  of  wheals  which  are  itchy  and 
persistent,  and  which  leave  behind  a  yellowish  or  brownish 
pigmentation.  The  disease  runs  a  chronic  course  of  months  or 
years. 

HERPES  SIMPLEX. 

(Fever  Blisters.) 

Definition. — An  acute  non-contagious  disease,  character- 
ized by  groups  of  small  vesicles  mounted  on  inflammatory 
bases. 


HERPUS  ZOSTEtt.  4S9 

Etiology. — Herpes  is  very  common  in  febrile  diseases, 
especially  pneumonia,  influenza,  malaria,  and  cerebro-spinal 
meningitis.  Local  irritation  also  predisposes  to  it.  It  is  de- 
pendent upon  neurotic  disturbance. 

Symptoms. — One  or  more  clusters  of  small  vesicles  appear, 
usually  on  the  face  or  genitalia.  The  vesicles  are  mounted  on 
an  inflammatory  base,  contain  clear  fluid,  and  show  no  ten- 
dency to  rupture.  Soon  their  contents  become  puriform,  dry 
up,  and  form  reddish-brown  crusts  which  fall  oiF  in  a  few 
days.  Burning  and  tiugling  precede  and  accompany  the 
eruption. 

Varieties. — When  it  appears  on  the  face,  it  is  termed 
herpes  facialis  ;  on  the  genitals,  herpes  progenitalis. 

Diagnosis. — Herpes  progenitalis  must  be  distinguished 
from  chancroid.  The  history,  the  superficial  character  of  the 
lesion,  the  burning  pain,  and  the  subsequent  course  will  indi- 
cate herpes. 

Treatment. — The  lesion  may  be  painted  with  flexible 
collodion,  or  the  following  lotion  employed  : — 

^   Zinc,  oxid.,  gr.  xv ; 
Glyceriai,    TTL  xv ; 
Liq.  plumbi  subacetat.  dil.,  TTL  x  ; 
Liq.  calcis,  3vj-|j.— M.     (Tilbury  Fox.) 
Sig. — Apply  locally. 

HERPES  ZOSTER. 

(Zona,  Shingles.) 

Definition. — An  acute  inflammatory  disease  characterized 
by  groups  of  small  vesicles  mounted  on  inflammatory  bases, 
associated  with  neuralgic  pain,  and  following  the  distribution 
of  certain  nerve-trunks. 

Etiology. — The  disease  commonly  depends  upon  a  periph- 
eral neuritis.  Injury,  exposure  to  cold,  and  damp  clothes 
predispose  to  it. 

Symptoms. — Clusters  of  vesicles  mounted  on  inflammatory 
bases  may  appear  on  any  part  of  the  body  ;  but  they  are  most 
frequently  observed  along  the  course  of  the  intercostal  nerves. 
Only  one  side  is  affected.  Sharp  neuralgic  pain  precedes  and 
accompanies  the  eruption.     The  fluid  in  the  vesicles  soon  be- 


440       DISEASES  OP  TliE  SKIN  ANt)  itS  At>I>t:NDAGES. 

comes  turbid,  dries  up,  and  forms  yellowish-brown  crustji 
which  fall  off  in  a  few  days. 

Prognosis.— Favorable. 

Treatment. — Tonics  are  often  indicated.  Bulkley  recom^ 
tnends  phosphide  of  zinc  in  doses  of  one-third  of  a  grain  every 
three  hours.  Morphia  is  sometimes  required  for  the  relief  of 
pain. 

Locally. — Sedative  applications  are  required ;  the  best  are 
flexible  collodion  with  morphine,  or  a  solution  of  menthol  or 
carbolic  acid,  followed  by  a  dusting-powder  of  oxide  of  zinc 
or  starch. 

^   Morpli.  sulph.,  gr,  viij  ; 
Collodii,  f5j.— M. 
Sig. — Apply  with  a  camel's-hair  brush. 

HERPES  IRIS. 

Definition. — An  inflammatory  disease,  characterized  by 
groups  of  vesicles  arranged  in  concentric  rings  which  present 
a  somewhat  variegated  appearance. 

Etiology. — The  causes  are  unknown.   The  disease  is  rare. 

Symptoms. — One  or  more  rings  of  vesicles  successively' 
appear  around  a  central  vesicle  or  papule.  The  different  ages 
of  the  rings  which  compose  the  patch  impart  to  the  latter  a 
variegated  appearance.  Burning  and  itching  are  often  atten- 
dant symj^toms.  The  hands,  arms,  and  feet  are  the  parts  most 
frequently  affected.  The  lesions  appear  in  successive  crops 
over  a  period  of  several  weeks.  In  some  instances  the  vesicles 
are  quite  large  and  resemble  the  blebs  of  pemiphigus. 

Prognosis. — Favorable,  but  recurrent  attacks  are  common. 

Treatment. — The  same  as  in  herpes  zoster. 

ACNE. 

(Acne  Vulgaris.) 

Definition. — An  inflammatory  disease  of  the  sebaceous 
glands,  characterized  by  papules  and  pustules  and  usually 
seated  on  the  face  or  back. 


ACNE.  441 

IEttology. — It  generally  develops  about  puberty.  Anaemia, 
menstrual  disorders,  and  gastro-intestinal  disturbances  predis- 
pose. Certain  drugs  like  iodide  and  bromide  of  potassium 
and  copaiba  may  induce  the  disease. 

Pathology. — Acne  lesions  result  from  the  irritation  ex- 
cited by  retained  sebaceous  matter,  hence  the  papules  and  pus- 
tules are  commonly  associated  with  blackheads,  or  comedones. 

Symptoms. — An  aggregation  of  small  papules,  pustules, 
and  comedones  about  the  face,  chest,  and  shoulders.  Pustules 
or  papules  predominate  according  as  the  disease  is  acute  or 
chronic.  New  lesions  develop  as  the  old  disappear,  so  that 
the  disease  usually  runs  a  protracted  course.  Subjective  phe- 
nomena are  absent. 

Varieties.  Acne  Papulosa. — In  this  form  the  lesion 
reaches  the  papular  stage  and  advances  no  further. 

Ac7ie  Pustulosa. — In  this  variety  the  papules  develop  into 
pustules. 

Acne  Indurata. — The  inflammation  is  deeply  seated,  the  base 
of  the  papule  or  pustule  is  firm,  and  the  lesion  is  sluggish. 

Acne  Atrophica. — In  this  form  the  lesions  are  followed  by 
small  scars  or  pits. 

Acne  Hyperlropjliica. — In  this  form  there  is  an  overgrowth 
of  connective  tissue  and  the  skin  becomes  thickened. 

Diagnosis. — The  distribution,  the  chronic  character  of  the 
affection,  the  involvement  of  the  sebaceous  glands,  and  the  as- 
sociation wdth  comedones  are  the  diagnostic  features  which 
separate  acne  from  all  other  affections. 

Prognosis. — Curable  under  persistent  treatment. 

Treatment. — The  general  health  must  be  improved.  The 
diet  should  be  nutritious,  but  easily  assimilable;  rich  food  must 
be  prohibited.  Constipation  should  be  relieved  by  mild  laxa- 
tives. In  the  anaemic  and  debilitated  iron,  quinine,  strychuine, 
and  cod-liver  oil  are  useful  remedies.  The  special  drugs  which 
have  been  recommended  are  arsenic,  ergot,  and  calx  sul])hurata. 
Arsenic  is  best  suited  to  the  sluggish  indurated  foi'ms  ;  and 
calx  sulphurata  (gr.  yV"6"  ^^^^  times  daily)  to  the  pustular 
variety. 

Local  Treatment. — In  the  acute  form  mild  applications 
should  be  employed,  like  the  following  calamine  lotion  : — 


442       DISEASES  OF  THE  SKIN  AND  ITS  APPENDAGES. 

^  Pulv.  zinc,  oxid.,  giij  ; 
Pulv.  calaminse,  ^ij  ; 
Glycerini,    f^ij  ; 
Aquse  calcis,  f^^vj. — M, 

In  chronic  cases  the  sebaceous  phigs  should  be  removed  by  a 
watch-key  and  the  pustules  incised.  Thorough  washing  with 
very  hot  water  and  green  soap  is  also  advisable.  The  best 
local  remedies  are  sulphur,  mercury,  and  resorcin. 

^  Calcis,  §ss ; 

Sulphur,  sublimat.,  §j  ; 

AqUiB,  §X.— M,      (VLE3UNCKX.) 

Evaporate  to  six  ounces  and  filter. 

Sig. — Apply  at  first  well  diluted  and  gradually  increase  the 
strength. 

Or— 

^  Sulphur,  prsecip.,  gj  ; 
Ung.  aqu0e  rosse, 

Petrolat.  moll.,  aa  3iv.— M.    (Yan  Haklingen.) 
Sig. — Apply  night  and  morning. 

Or— 

^  Hydrarg.  ammoniat.,  gr.  xx-xl; 
Ung.  aqua?  rosse,  ^j. — M. 
Sig. — Use  night  and  morning. 

Or— 

'^  Ammon.  sulplioichthyol., 
Aquse  destillat., 
Glycerini, 

Dextrini,  aa  55. — M    (Unka.) 
Sig. — Use  locally. 

ACNE  ROSACEA. 

Definition. — A  chronic  affection,  usually  located  on  the 
face  in  the  region  of  the  nose,  and  characterized  by  marked 
hypersemia,  dilatation  of  the  vessels,  overgrowth  of  tissue,  and 
acne  lesions. 

Etiology. — Anaemia,  menstrual  disorders,  gastric  disturb- 
ances, exposure  to  extremes  of  temperature,  and  intemperance 
are  the  usual  predisposing  causes. 

Symptoms. — The  affected  area  is  of  a  deep-red  color ;  the 
vessels  are  dilated ;  the  skin  is  thickened  and  lumpy,  and 


FUEUNCTJLITS.  443 

acne  lesions  coexist.  In  advanced  cases  the  nose  may  become 
extremely  large  and  lobulated  (Eliinophyma). 

Subjective  phenomena  are  generally  absent. 

Diagnosis.  Lupus  Vulgaris. — In  this  disease  there  are 
soft  pale-red  papules,  ulceration,  and  cicatrization,  and  no  en- 
largement of  the  bloodvessels. 

Peognosis. — Unless  the  hypertrophy  is  marked,  the  dis- 
ease is  curable  under  protracted  treatment. 

Treatment. — The  general  treatment  is  the  same  as  in  acne 
vulgaris. 

Local  Treatment. — Sulphur  and  mercury  are  the  most  reli- 
able remedies.  Vleminckx's  solution  is  very  useful.  Dilated 
vessels  should  be  destroyed  by  electrolysis.  Large  hypertro- 
phies may  be  removed  by  the  knife. 

FURUNCULUS. 

(Boil.) 

Definition. — A  miniature  dermal  abscess. 

Etiology. — Single  boils  are  usually  due  to  local  irritation. 
Their  appearance  in  crops  (Furunculosis)  is  usually  indicative 
of  impaired  health.  The  entrance  of  pus  cocci  into  the  skin 
is  always  essential  to  their  production. 

Diagnosis. — Furuncles  must  be  distinguished  from  carbun- 
eles  ;  the  latter  are  single,  large,  flattened  at  their  summits,  and 
have  multiple  openings. 

Treatment. — In  furunculosis  the  cause  should  be  searched 
for  and,  if  possible,  removed.  Tonics  like  iron,  quinine,  cod- 
liver  oil,  and  hypophosphites  are  often  very  useful.  Calx 
sulphurata  (yV~6"  S^^-  thrice  daily  after  meals)  sometimes  proves 
serviceable.  A  solution  of  boric  acid  or  of  corrosive  sublimate 
may  be  applied  locally.  The  following  paste  will  often  abort 
them  : — 

Icbthyol, 
Ung.  hydrarg., 
Ext.  belladonnae,  aa  3j. — M. 
Sig. — Apply  locally  and  make  pressure  with  strips  of  adhesive 
plaster. 


444      DISEASES  OP  THE  SKIN  AND  ITS  APPENDAGES. 

CABBUNCULUS 

(Anthrax.) 

Definition. — A  circumscribed  inflammation  of  the  skin 
and  deeper  tissues,  characterized  by  a  dark-red,  painful  node 
which  breaks  down  and  evacuates  through  several  apertures. 

Etiology. — Lowered  vitality  from  any  cause  predisposes. 
They  are  especially  common  in  diabetes.  The  exciting  cause 
is  a  special  microbe. 

Symptoms. — A  dark -red,  painful,  flattened  node  appears 
surrounded  by  a  dusky-red  area  of  induration.  In  a  week  or 
ten  days  suppuration  begins,  and  the  contents  are  discharged 
through  several  orifices.  There  is  generally  marked  con- 
stitutional disturbance.  The  most  common  seats  are  the  nape 
of  the  neck,  back,  and  buttocks. 

Peognosis.  —  Guardedly  favorable.  Death  is  not  an  in- 
frequent termination  in  the  old  and  debilitated. 

Teeatment. — Generally  tonics  like  quinine,  iron,  and 
whiskey  are  indicated.  Opium  may  be  required  to  relieve 
pain. 

Local  Treatment. — In  the  early  stage  they  may  be  aborted 
by  a  central  injection  of  ten  to  twenty  minims  of  a  5  or  10  per 
cent,  solution  of  carbolic  acid  in  glycerine.  When  not  seen 
until  abortion  is  too  late,  firm  compression  may  be  made  by 
straps  applied  concentrically,  leaving  the  central  orifice  free 
for  the  discharge  of  sloughs  ;  an  antiseptic  dressing  may  be 
applied  over  the  straps. 

PSORIASIS. 

Definition. — A  chronic  inflammatory  disease,  character- 
ized by  red,  scaly,  sharply-circumscribed,  elevated  lesions. 

Etiology. — Psoriasis  usually  develops  in  young  adults. 
Heredity,  the  gouty  diathesis,  pregnancy,  and  lactation  seem  to 
predispose.  It  is  as  common  in  the  robust  as  in  the  debilitated. 
It  is  non-contagious. 

Pathology. — A  localized  hypertrophy  of  tlie  rete  mucosum 
associated  with  inflammation. 


PSORIASIS.  445 

Symptoms. — Little  red  spots  appear  on  the  body,  and 
gradually  grow  until  they  reach  the  size  of  a  dollar.  The 
lesions  are  of  a  dull  pink  or  red  color,  sharply  defined,  some- 
what elevated,  surrounded  by  healthy  skin,  and  covered  with 
abundant  dry,  pearly,  overlapping  scales.  These  scales  are 
readily  detached,  leaving  behind  a  dry,  slightly  excoriated 
surface.  The  lesions  may  be  uniformly  distributed  over  the 
entire  body,  but  usually  the  extensor  surfaces  are  more  affected ; 
a  symmetrical  arrangement  is  often  observed.  Itching  is 
slightly  or  entirely  absent.  After  a  variable  time  the  centre  of 
the  patch  disappears  and  leaves  behind  a  spot  of  healthy  skin 
which  gradually  increases  until  no  trace  of  the  lesion  remains. 
The  disease  runs  a  protracted  course  of  months  or  years,  im- 
proving in  the  summer  and  growing  worse  in  the  winter. 

Diagnosis.  Eczeimi.' — In  this  disease  the  patches  are  not 
sharply  defined,  but  shade  ofP  gradually  into  the  surrounding 
skin ;  there  is  marked  itching ;  there  is  usually  a  decided  dis- 
charge, and  healing  begins  at  the  periphery  instead  of  at  the 
centre  as  in  psoriasis. 

Seborrhcea. — In  this  affection  the  lesions  are  usually  confined 
to  the  scalp  and  face,  while  psoriasis  is  general ;  the  scales  are 
gray  and  greasy ;  the  patches  are  not  circumscribed,  and  lack 
the  inflammatory  character  of  psoriasis. 

Pajpido-squamous  Syphiloderm. — The  history,  the  associated 
symptoms  of  syphilis,  the  coppery  color  of  the  lesions,  the 
scant  scaling,  the  special  tendency  to  involve  the  hands  and 
soles  will  render  the  diagnosis  apparent. 

Prognosis. — The  disease  disappears  under  treatment,  but 
relapse  generally  follows  after  a  longer  or  shorter  period. 

Treatment. — The  general  health  may  require  attention. 
In  the  gouty  alkalies  are  of  value  ;  and  in  the  anaemic  iron  and 
cod-liver  oil  are  indicated.  Arsenic  is  often  of  considerable 
value ;  it  should  be  given  in  small  doses  cautiously  increased. 
Iodide  of  potassium  (gr.  x-xx  thrice  daily)  is  sometimes  rec- 
ommended. 

Local  Treatment — The  scales  should  be  removed  by  alkaline 
baths  before  local  applications  are  made.  The  best  local 
remedies  are  tar,  chrysarobin,  salicylic  acid,  resorcin,  sulphur, 
and  ammoniated  mercury. 


446       DISEASES   OF  THE  SKIN  AND   ITS   APPENDAGES. 

J^L  Acid,  chrysoplianic,  gr.  x; 
Adipis  benzoat.,  gj. — M. 
Sig. — Apply  twice  daily. 

Or— 

1^   Sulphur,  sublimat., 
Ol,  cadini,  aa  ^iv  ; 
Sapon.  virid., 
Adipis,  aa  ^j  ; 
Cretse  prsep.,  ^ijss.— M.     (Wilkinson.) 

ECZEMA. 

(Tetter.) 

Definition. — A  non-contagious  iuflaramatoiy  disease  of 
the  skin,  characterized  by  multiform  lesions — erythema,  pap- 
ules, vesicles,  pustules,  scales,  and  crusts — and  associated  with 
infiltration,  itching,  and  more  or  less  discharge. 

Etiology. — It  is  most  common  in  the  young  and  in  the 
aged.  Digestive  disturbances,  debility,  gout,  and  rheumatism 
jDredispose  to  its  development.  It  may  be  due  to  external 
irritants  like  cold,  heat,  the  rhus-plant,  hard  soaps,  certain 
dyes,  etc. 

Pathology. —  Congestion  and  infiltration  of  the  various 
layers  of  the  skin. 

Varieties. — E.  erythematosum,  E.  papulosum,  E.  vesicu- 
losum,  E.  pustulosum,  E.  squamosum,  and  E.  rubrum. 

Eczema  Er3^hemat0SUm. — This  form  consists  in  irregular 
patches  marked  by  swelling,  redness,  and  slight  scaling,  and 
accompanied  by  itching  and  burning.  The  most  common  seat 
is  the  face. 

Eczema  Papillosum, — In  this  form  there  is  a  close  aggrega- 
tion of  minute  acuminated  papules  accompanied  by  severe 
itching.  It  is  frequently  associated  with  the  vesicular  variety. 
The  most  common  seat  is  the  extremities. 

Eczema  Vesiculosmn.— This  consists  in  an  ill-defined  red 
patch  surmounted  by  minute  vesicles,  and  accompanied  by 
intense  itching.  The  vesicles  soon  rupture  and  leave  a  raw, 
weeping  surface  which  becomes  more  or  less  covered  with 
crusts.  In  children,  it  is  most  common  on  the  face  ;  in  adults, 
on  the  extremities. 


ECZEMA.  447 

Eczema  Pustulosiun  {Eczema  Impetiginosum). — This  consists 
in  an  aggregation  of  small  pustules  which  break  and  lead  to  the 
formation  of  thick  yellowish  crusts.  Itching  is  not  marked. 
It  is  frequently  associated  with  the  vesicular  variety.  It  is 
most  commonly  observed  on  the  face  and  scalp  of  poorly- 
nourished  children. 

Eczema  Squamosmn. — In  this  form  there  are  irregular  ill- 
defined  red  patches  accompanied  by  considerable  scaling.  It 
differs  from  the  erythematous  form  in  the  large  amount  of 
scaling.     Its  most  common  seat  is  the  scalp. 

When  there  is  a  marked  tendency  to  Assuring,  as  in  chap- 
ping, this  form  is  termed  eczema  fissum  ;  and  when  there  is  a 
tendency  to  the  formation  of  warty  excrescences,  it  is  termed 
eczema  verrucosum. 

Eczema  Rubrum  {Eczema  Madkkvns). — This  is  a  secondary 
variety  and  is  recognized  by  a  raw,  dark -red,  moist  surface, 
more  or  less  covered  with  thick  yellowish-red  crusts.  The 
itching  may  be  severe.  In  children  it  is  frequently  noted  on 
the  face,  and  in  old  people  on  the  extremities. 

Diagnosis.  Scabies. — The  history  of  contagion ;  the  loca- 
tion of  the  lesions — between  the  fingers,  on  the  wrists,  under 
the  mammae,  in  the  axillse ;  and  the  presence  of  burrows  will 
indicate  scabies. 

Pswiasis. — The  sharply-defined  patches,  the  dry  scaling, 
the  absence  of  marked  itching,  the  symmetrical  distribution, 
and  the  predilection  for  extensor  surfaces  will  indicate 
psoriasis. 

Acne  Rosacea. — The  presence  of  acne  papules  and  pustules 
and  of  dilated  bloodvessels,  and  the  absence  of  itching  will 
distinguish  acne  rosacea  from  erythematous  eczema. 

Seborrhoea. — The  greasy  scales  and  the  absence  of  itching 
and  of  all  inflammatory  symptoms  will  indicate  seborrhoea. 

Sycosis'. — The  limitation  of  the  lesions  to  the  hair-follicles 
of  the  face  and  the  absence  of  itching  will  distinguish  sycosis 
from  eczema. 

Peognosis. — Generally  favorable  under  persistent  and  judi- 
cious treatment. 

Treatment.  General  Treatment. — The  health  must  be 
improved.      Tonics   are  frequently  indicated.      In  strumous 


448       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

children  cod-liver  oil  may  be  of  extreme  value.  Disturbances 
of  the  gastro-intestinal  tract  are  frequently  present,  and  will 
require  appropriate  treatment.  In  the  gouty  and  rheumatic 
the  alkaline  mineral  waters,  colchicum,  and  the  salts  of  lithium 
are  indicated.  Constipation  must  always  receive  attention. 
Of  the  special  internal  remedies,  arsenic  is  the  most  important ; 
it  is,  however,  only  indicated  in  the  chronic  cases  in  which 
bright  redness,  itching,  and  weeping  are  absent. 

Exiernal  Treatment — In  acute  cases  with  marked  inflam- 
matory symptoms,  soothing  applications  should  be  employed. 
A  saturated  solution  of  boric  acid  may  be  dabbed  on  for  five 
or  ten  minutes,  and  may  be  followed  by  zinc  ointment  spread 
on  lint ;  when  there  is  much  itching  carbolic  acid  is  very 
useful : — 

^   Acid,  carbolic,  3j; 
Glyceriiii,    gij  ; 
Aquse,  q.  s.  ad  f^viij. — M. 

Sig. — Apply  locally. 

The  following  is  also  frequently  used : — 
^   Zinc,  oxid.,  gss  ; 

Pulv.  calaminse  praep.,  9iv  ; 

Glycerini,    f'ij  ; 

Liq.  Calais,  f^vij. — M. 
Sig. — Shake  and  api)ly  locally. 

In  chronic  cases  crusts  and  scales  should  be  removed  by 
soap  and  water  or  by  : — 

'^L   Saponis  virid.,  ^ij ; 
Alcoholis,  5j.— M. 
Sig. — Apply  thoroughly  and  remove  with  warm  water. 

The  best  external  applications  are  salicylic  acid,  tar,  mer- 
cury, and  resorcin  : — 

^.   Acid,  salicylic,  gr.  v-x; 
Petrolat.  moll.,  Z'vf\ 
Amyli, 
Zinci  oxid.,  aa  3ij.— M. 

(Stelwagon  and  Duhring.) 
Sig.— Apply  twice  daily. 

Or— 

^   Hydrarg.  ammoniati,  ^ss  ; 
Liq.  picis  alkaliu.,  .5j  ; 
Ung.  aquse  rosae,  5j. — M. 


LICHEN   RUBER   AND   LICHEN   PLANUS.  449 

Or— 

^   01.  cadini,  f.^ss  ; 
Glyceriui,    fgj  ; 

Ung.  diachyli,  f^iiss.— M.      (TiLBURY  Fox.) 
Sig. — Apply  locally. 

LICHEN  RUBER  AND  LICHEN  PLANUS. 

Lichen  Ruber. — This  is  an  extremely  rare  disease,  charac- 
terized by  the  eruption  of  small,  red,  glazed,  acuminated  papules 
which  show  no  tendency  to  coalesce,  and  which  are  associated 
with  itching  and  failure  of  general  health.  The  disease  runs 
a  chronic  course,  and  may  prove  fatal  through  exhaustion. 

Lichen  Planus. — This  form  is  characterized  by  an  eruption 
on  the  extremities  of  small,  red,  flat  papules  which  tend  to 
spread,  and  by  coalescing  form  dull-red,  irregular  patches. 
The  latter  at  first  have  a  smooth  and  shiny  appearance,  but 
later  are  slightly  scaly.  There  is  more  or  less  itching,  but  no 
impairment  of  the  general  health.  As  the  old  lesions  disap- 
pear new  ones  take  their  place. 

Etiology. — These  affections  are  most  frequently  observed 
in  poorly-nourished,  middle-aged  males. 

Treatment. — The  general  health  must  be  improved  by 
good  food  and  such  tonics  as  iron,  strychnine,  and  cod-liver 
oil.  Arsenic  is  of  considerable  value.  Locally,  ointments  of 
tar  or  mercury  are  useful. 

Lichen  Scrofulosis. 

This  is  a  chronic  affection  occurring  chiefly  in  children  of  a 
strumous  diathesis,  and  characterized  by  small,  pale-red,  or 
salmon-colored  scaly  papules.  They  tend  to  form  in  groups, 
and  are  most  frequently  observed  on  the  trunk.  Itching  is 
absent.     The  disease  runs  a  chronic  course. 

Treatment. — Remedies  like  iron,  quinine,  and  cod-liver 
oil  are  indicated.     Hebra  recommends  the  last  remedy  as  a 
local  application. 
29 


450       DISEASES   OF   THE  SKIN   AND   ITS  APPENDAGES. 

PRURIGO. 

Definition. — A  chronic  iuflammatoiy  disease,  characterized 
by  a  general  eruption  of  minute,  discrete  papules,  accompanied 
by  marked  itching. 

Etiology. — It  is  most  commonly  observed  in  the  poor  and 
ill-fed  of  Europe.  It  develops  in  early  childhood  and  persists 
through  life. 

Symptoms. — An  eruption  of  small,  discrete,  deeply-situated, 
pale-red  papules  appears  on  the  body,  especially  on  the  back 
and  extensor  surfaces  of  the  extremities.  The  skin  is  harsh, 
dry,  and  thickened,  and  covered  with  numerous  scratch-marks 
induced  by  the  intense  itching. 

Prognosis. — Unfavorable ;  it  usually  persists  through  life. 

Treatment. — The  general  health  must  be  improved  by 
good  food  and  the  use  of  nutrient  tonics  like  iron  and  cod- 
liver  oil.  Frequent  bathing,  followed  by  ointments  of  tar, 
sulphur,  or  naphthol,  gives  relief. 

DERMATITIS  HERPETIFORMIS. 

(Herpes  Gestationis,  Duhring's  Disease.) 

Definition. — A  chronic  inflammatory  disease,  characterized 
by  multiform  lesions  which  form  in  groups,  and  which  are 
associated  with  intense  itching. 

Etiology. — Women  are  more  commonly  affected  than 
men.  Pregnancy,  lactation,  and  menstrual  disorders  seem 
to  exert  a  predisposing  influence. 

Symptoms.  Erythematoits  Form. — This  is  characterized  by 
the  appearance  in  crops  of  erythematous  patches  which  are 
associated  with  considerable  itching. 

Papular  Form. — Groups  of  papules  appear  in  crops,  and 
are  frequently  associated  with  erythema  vesicles  and  scratch- 
marks. 

Vesicular  Form. — Groups  of  irregular-shaped  vesicles  resem- 
bling herpes  appear  in  crops  and  are  often  associated  with 
erythema,  pustules,  and  scratch-marks. 

Fmtular  Form. — This  resembles  the  former,  but  the  vesicles 
are  replaced  by  pustules. 


DERMATITIS.  451 

Bullous  Form. — Large  irregular-shaped  blebs  appear  in 
crops  and  tend  to  group.  Vesicles  and  patches  of  erythema 
are  also  frequently  present. 

Ilixed  Form. — Vesicles,  erythematous  patches,  pustules, 
papules,  and  blebs  appear  in  association,  come  out  in  crops, 
and  are  attended  with  intense  itching. 

In  the  pustular,  bullous,  and  mixed  forms  there  may  be 
marked  constitutional  disturbances. 

Peognosis. — Guardedly  favorable.  The  disease  runs  a 
chronic  course.     Eelapses  are  very  common. 

Treatment. — Tonics  are  generally  indicated.  Lotions  of 
boric  or  carbolic  acid  may  be  employed  to  allay  itching,  and 
may  be  followed  by  a  dusting-powder. 

DERIVIATITIS. 

Definition. — Inflammation  of  the  skin  resulting  from  the 
action  of  some  irritant. 

DennatitiS  Traumatica. — This  term  is  applied  to  inflam- 
mation of  the  skin  resulting  from  traumatism. 

Treatment. — The  removal  of  the  cause  and  the  applica- 
tion of  soothing  remedies  will  usually  suffice. 

Dermatitis  Venenata. — The  term  is  applied  to  inflamma- 
tion of  the  skin  resulting  from  the  application  of  vegetable, 
animal,  or  chemical  irritants.  Kotable  examples  of  this  form 
of  dermatitis  are  observed  in  susceptible  people  after  exposure 
to  the  influence  of  poison  ivy  {Rhus  Toxicodendron),  poison 
oak  {Rhus  Venencda),  or  poison  sumach  {Rhus  Diversiloha). 

Symptoms  of  Ehus-poiso^ing. — The  affection  resembles 
acute  eczema,  and  may  appear  in  a  few  hours  or  not  until 
the  lapse  of  several  days  after  exposure  to  the  plant.  It  is 
generally  observed  on  the  face  or  hands.  The  part  becomes 
red  and  swollen,  and  soon  minute  papules  and  vesicles  appear. 
It  gives  rise  to  considerable  burning  and  itching.  As  a  rule, 
it  subsides  in  a  few  days,  but  in  patients  with  sensitive  skin 
it  may  linger  for  several  weeks. 

Treatment. — The  part  should  first  be  bathed  with  castile 
soap  and  tepid  water,  and  then  treated  with  some  sedative 
lotion  or  ointment.     Black  wash  may  be  dabbed  on,  and  zinc 


452       DISEASES  OF  THE  SKIN   AND   ITS  APPENDAGES. 

ointment  subsequently  applied ;  or  a  saturated  solution  of  boric 
acid  may  be  followed  by  zinc  ointment.  When  there  is  marked 
itching  a  weak  solution  of  carbolic  acid  (5j  tD  Oj)  is  useful. 
The  fluid  extract  of  griudelia  robusta  has  been  highly  recom- 
mended ;  it  may  be  applied  in  the  strength  of  half  an  ounce 
to  a  pint  of  water. 

Dermatitis  Calorica. — This  term  is  applied  to  the  inflamma- 
tion of  the  skin  resulting  from  extreme  heat  or  cold.  Pernio, 
or  chilblain,  is  characterized  by  redness,  swelling,  intense 
burning  and  itching,  and  results  from  a  sudden  change  from 
a  low  temperature  to  a  high  temperature.  Frost-bite  is  char- 
acterized by  congelation  ;  the  part  is  of  a  dull-white  color  and 
is  anaesthetic ;  subsequently  inflammation  or  gangrene  develops. 

Burns  and  scalds  result  from  the  application  of  heat,  and 
are  divided  into  degrees  according  to  the  depth  to  which  the 
destructive  process  extends. 

Treatiment. — In  pernio,  or  chilblain,  the  part  should  first 
be  rubbed  with  snow  or  bathed  in  ice-water  until  the  circula- 
tion is  re-established  ;  and  then  an  application  made  of  nitrate 
of  silver  (gr.  v  to  the  ounce  of  distilled  water)  or  of  tincture 
of  iodine. 

In  superficial  bm^ns  or  scalds  one  of  the  following  remedies 
may  be  applied  :  Phenol  sodique,  carron  oil  (equal  parts  of  lin- 
seed oil  and  lime-water),  powdered  bicarbonate  of  sodium,  or: — 

^   Acidi  carbolic,  gr.  viij  ; 

Yaseliu.,  ,pj.— M.     (Bellvue  Hospital.) 
Sig. — Spread  on  lint  aud  apply  where  the  skin  is  broken. 

Dermatitis  Medicamentosa. — This  term  is  applied  to  the 

various  cutaneous  eruptions  which  follow  the  internal  use  of 
certain  drugs. 

Belladonna  or  Atropia. — These  drugs  produce  a  diifuse 
erythematous  rash  resembling  that  of  scarlet  fever,  but  it 
lacks  the  punctiform  character  of  the  latter.  It  usually  ap- 
pears on  the  face,  neck,  and  chest,  and  is  associated  with  dry- 
ness of  the  throat,  rapid  pulse,  and  if  the  dose  has  been  large, 
dilated  pupils. 

Cubebs. — This  drug  sometimes  produces  an  erythema  asso- 
ciated with  minute  papules. 


ECTHYMA.  453 

Copaiba. — The  rash  may  be  macular,  papular,  or  like  that 
of  urticaria. 

Bromide  of  Potassium. — The  eruption  resembles  acne  and 
consists  of  papules  and  pustules. 

Iodide  of  Potassium. — The  eruption  may  be  erythematous, 
papular,  pustular,  urticarial,  or  purpuric.  The  most  common 
eruption  resembles  acne,  but  the  lesions  are  bright-red  in  color 
and  widely  distributed  over  the  surface  of  the  body. 

Arsenic. — The  eruption  may  be  erythematous,  papular, 
vesicular,  or  pustular. 

Antipyrin. — This  drug  not  infrequently  produces  a  wide- 
spread papular  eruption. 

Quinine. — The  rash  is  usually  erythematous,  though  an 
urticarial  eruption  has  been  observed. 

Salicyl  Compounds. — The  eruption  is  usually  erythematous 
or  urticarial. 

Borax. — This  drug  occasionally  produces  an  eruption  resem- 
bling psoriasis. 

Chloral. — The  eruption  is  usually  erythematous  or  urticarial. 

Dermatitis  Exfoliativa. 

This  is  a  rare  aflPection,  characterized  by  diffuse  redness  of 
the  skin,  high  fever  and  its  associated  phenomena,  and  des- 
quamation. It  is  interesting  from  its  close  resemblance  to 
scarlet  fever,  from  which  it  may  be  distinguished  by  the  history 
and  the  absence  of  sore  throat,  and  a  "  strawberry"  tongue. 

ECTHYMA. 

Definition. — An  inflammatory  affection,  characterized  by 
the  appearance  of  discrete,  flat  pustules,  which  vary  in  size 
from  a  pea  to  a  five-cent  piece,  and  which  are  surrounded  by 
a  distinct  red  areola. 

Etiology. — Male  sex,  middle  life,  bad  hygiene,  and  de- 
bility are  predisposing  factors. 

Symptoms. — Flat,  yellow  pustules  appear  in  crops.  They 
are  surrounded  by  a  distinct  red  areola  and  soon  dry  up,  form- 
ing reddish-brown  crusts.     Slight  excoriation  and  pigmenta- 


454       DISEASES    OF   THE    SKIX    A^"T)   ITS    APPENDAGES. 

tion  sometimes  remain  after  the  separation  of  the  crusts. 
Subjective  phenomena  are  usually  absent. 

DiAG^rosis. — The  acute  coui-^se,  the  absence  of  ulceration, 
and  the  absence  of  history  and  of  associated  symptoms  of 
svphilis  will  separate  it  frijm  ihe  pU'Stidar  syphiUde. 

Impef.igo. — In  this  atiectiijn  the  lesions  are  not  flat ;  they  are 
not  distinctly  inflammatory  :  and  the  crusts  are  light  yellow, 
not  reddish-brown.  Impetigo  occurs  most  frequently  in  child- 
ren, who  may  l>e  quite  robust. 

Peogxosis. — Favorable. 

Tezatment.  —  Constitutional  treatment  is  generally  re- 
C|uired.  Such  tonics  as  iron,  quinine,  strychnine,  and  eod- 
Hver  oil  are  often  idicated. 

Local  Treatment. — The  crusts  should  be  removed  and  some 
stimulating  ointment  applied,  as  the  fallowing  : — 

^  Hydrarg.  ammoniat..  gr.  s  : 
I7n2f.  zinci  oxidi.  5i. — M. 


PE3IPHIGrS. 

DErrsrETio:^'. — A  non-contagious  inflammatory  disease,  char- 
acterized by  the  ernption  of  successive  crops  of  bullae  or  blebs. 

Etiology. — Female  sex,  nervous  prostration,  heredity,  and 
injury  to  the  peripheral  nerves  are  predisposing  factors. 

VAEiETrE.-, — Pemphigus  vulgaris  and  pemphigus  foliaceus. 

Pemphigus  Vulgaris. — This  form  usually  runs  a  chronic 
course  and  is  characterized  by  successive  crops  of  blebs,  vary- 
ing in  size  from  a  small  pea  to  a  large  walnut.  They  are 
thoroughlv  distended  with  fluid,  which  is  at  first  clear  ]jut 
su]>sequently  tui^bid.  As  a  rule,  they  do  not  rupture,  but  dis- 
appear in  the  CL.urse  of  Ave  or  six  days,  their  cr.ntents  beiug 
graduallv  absorbed.  After  al  i-orption  a  thin  pellicle  remains, 
which  dries  and  is  subse'jiiently  detached,  leaving  behind  a 
slightlv  pigmented  spot.  So  pan  C'f  the  body  is  exempt ;  and 
as  one  set  of  blebs  disippears,  new  ones  rapidly  develop,  and 
so  the  disease  continues  for  many  years. 

In  severe  cases  there  may  be  considerable  itching  and  burn- 
ing attending  the  eruption. 


niPETTGO.  455 

Pemphigns  Foliaceus. — This  rare  and  grave  form  of  pem- 
phigus is  characterized  br  crops  of  blebs,  which  are  flaccid  and 
filled  with  a  turbid  fluid  almost  from  the  begimiing.  They 
soon  rupture  and  form  thick  crusts,  which  separating  leave 
behind  red  weeping  surfaces.  The  crops  follow  each  other  in 
rapid  succession,  and  at  times  the  whole  body  may  be  covered 
with  blebs  and  scabs.  The  disease  may  last  several  years, 
death  ultimately  resulting  from  exhaustion. 

DiAGXosis.  Bullous  Syphiloderm. — The  history,  the  asso- 
ciated symptoms  of  syphilis,  the  thick,  yellow,  stratified  crusts, 
and  the  underlying  ulceration  will  serve  to  separate  this  affec- 
tion from  pemphigus. 

Impetigo  Contagiosa. — The  acute  course,  the  contagious 
and  auto-inoculable  character  of  the  affection,  and  the  umbili- 
cation  of  the  blel)S  will  separate  impetigo  contagiosa  from 
pemphigus. 

Peognosis. — The '  prognosis  should  be  guarded.  Pemphi- 
gus vulgaris  runs  a  long  course  and  is  often  intractable.  Pem- 
phigus foliaceus  often  proves  fatal  through  exhaustion. 

Teeatmext, — The  diet  should  be  nutritious,  but  carefully 
adapted  to  the  stomach.  The  patient  should  be  placed  under 
the  best  hygienic  conditions.  Tonics  like  iron,  quinine,  phos- 
phorus, cod-liver  oil,  and  strychnine  are  usually  indicated.  In 
some  cases  arsenic  may  prove  useftil. 

Local,  Treatment. — The  blebs  may  be  punctured  and 
subsequently  dressed  with  zinc  ointment. 

I3IPETIGK). 

Definition. — An  acute  inflammatoiy  disease,  characterized 
by  an  eruption  of  discrete  pustules  varying  in  size  from  a  pea 
to  a  cherry. 

Etiology. — The  exciting  cause  is  unknown.  It  is  most 
commonly  observed  in  children. 

Symptoms. — A  pustular  eruption  appeai-s  generally  on  the 
face  and  extremities.  The  pustules  are  generally  few  in  num- 
ber, and  are  discrete,  tense,  and  surrounded  by  a  slight  areola. 
In  a  few  days  they  dry  up  and  form  thin  yellowish-brown 


456       DISEASES   OF  THE  SKIN   AND   ITS  APPENDAGES. 

crusts,  which  soon  drop  off  and  leave  behind  a  normal  surface. 
Subjective  phenomena  are  absent. 

Diagnosis.  Ecthyma. — This  affection  occurs  most  fre- 
quently in  debilitated  adults ;  the  pustules  are  flat,  sur- 
rounded by  a  distinct  areola,  and  dry  to  brown  crusts  which 
separate  and  leave  a  pigmented  excoriated  surface. 

Impetigo  Contagiosa. — As  the  name  implies,  this  affection  is 
contagious  and  is  auto-iuoculable ;  its  pustules  are  flat  and  um- 
bilicated,  and  dry  up  and  form  lamellated,  thin,  yellow  crusts. 

Peognosis. — Favorable.  It  terminates  spontaneously  in  a 
few  days  or  a  week. 

Treatment. — Open  the  pustules  and  apply  some  simple 
protective  ointment,  like  that  of  oxide  of  zinc. 

IMPETIGO  CONTAGIOSA. 

Definition. — An  acute  contagious  inflammatory  disease, 
characterized  by  flat,  yellowish  blebs  which  dry  up  and  form 
thin,  yellow,  lamellated  crusts. 

Etiology. — Its  exciting  cause  is  unknown.  It  is  most 
frequently  observed  in  debilitated  children. 

Symptoms. — The  eruption  is  most  frequently  observed  on 
the  face  and  extremities  ;  it  generally  appears  in  crops,  and  is 
at  first  vesicular.  The  vesicles  grow,  and  are  soon  converted 
into  flat,  umbilicated  pustules  which  vary  in  size  from  a  pea 
to  a  large  walnut.  They  have  a  slight  red  areola.  Itching 
is  slight  or  entirely  absent.  In  some  cases  there  is  moderate 
fever  with  its  associated  phenomena.  In  a  few  days  the  blebs 
dry  up  and  form  thin,  yellow,  lamellated  crusts  which  separat- 
ing leave  a  slightly  excoriated  surface.  The  disease  is  con- 
tagious, and  the  lesions  are  auto-inoculable. 

Diagnosis.  Eczema. — In  this  disease  the  pustules  are 
similar,  more  confluent,  excite  intense  itching,  and  are  asso- 
ciated with  inflammation  and  infiltration  of  the  surrounding 
skin. 

Sim-pie  Impetigo. — This  affection  is  not  contagious  or  auto- 
inoculable;  the  pustules  are  tense,  not  flat  or  umbilicated; 
and  the  subsequent  crusts  are  yellowish-brown  and  are  not 
followed  by  excoriation. 


MILIARIA.  467 

Prognosis. — Favorable.  It  terminates  spontaneously  in  a 
few  days  or  weeks. 

Treatment. — A  slight  stimulating  ointment  like  the  fol- 
lowing is  sometimes  useful : — 

^  Hydrarg.  ammon.,  gr.  v  ; 
Adipis,  Ij.— M. 
Sig. — Apply  to  the  surface  afler  removal  of  the  crusts. 

MTLIAKIA. 

(Prickly  Heat.) 

Definition. — An  acute  inflammatory  disease  of  the  sweat- 
glands,  characterized  by  a  discrete  eruption  of  minute  papules 
and  vesicles. 

Etiology. — Childhood  and  high  temperature  are  the  prin- 
cipal predisposing  causes. 

Symptoms. — The  eruption  generally  appears  on  the  trunk, 
and  consists  of  minute  closely-aggregated  red  papules  or  clear 
vesicles.  The  lesions  are  discrete,  and  excite  some  burning 
and  itching.     It  is  generally  associated  with  free  perspiration. 

Diagnosis. — Eczema  papulosum  differs  from  miliaria  in 
that  the  papules  are  larger,  appear  more  gradually,  disappear 
more  slowly,  and  excite  intense  itching. 

Eczema  vesiculosum  differs  from  miliaria  in  that  the  vesicles 
are  large,  disappear  more  slowly,  show  a  tendency  to  break, 
and  are  associated  with  marked  itching. 

Sudamen  differs  from  miliaria  in  that  it  lacks  all  inflamma- 
tory characteristics. 

Prognosis. — Favorable.  Obstinate  cases  may  persist  for 
several  weeks. 

Treatment. — The  general  health  may  require  attention. 
The  diet  should  be  light,  and  easily  assimilable.  Constipation 
should  be  relieved  by  saline  laxatives.  Locally,  a  simple 
dusting-powder  is  generally  all  that  is  required. 

^  Pulv.  amyli,  ^vj  ; 
Zinc,  oxidi,  giss ; 

Pulv.  camph.,  3ss.— M.     (Hakdawat.) 
Sig. — Dusting-powder, 


458       DISEASES   OF   THE  SKIN  AXD   ITS   APPENDAGES. 

Or— 

^  Zinc,  carbonat.  prsecip.,  ^iv; 
Zinc,  oxidi,  3ij  ; 
Glycerini,    f  ^ij  ; 

Aq.  rosse,  fgviij.— M.     (Tilbury  Fox.) 
Sig. — Apply  locally. 

ALBINISM. 

Definition. — A  congenital  deficiency  of  pigment. 

Etiology. — Beyond  heredity,  no  cause  is  known.  Partial 
albinism  is  more  common  in  the  negro. 

Symptoms. — In  complete  albinism  the  skin  is  white ;  the 
hair  is  thin,  soft,  and  very  light  in  color  ;  the  pupils  appear 
red,  the  eyes  are  very  sensitive  to  light,  and  the  iris  and 
choroid  are  deficient  in  pigment. 

VITILIGO. 

(Leucodenna.) 

Definition. — An  acquired  cutaneous  affection,  character- 
ized by  milk-white  patches  which  are  surrounded  by  areas  of 
increased  pigmentation. 

Etiology. — The  disease  seems  to  be  more  common  in  the 
tropics  and  in  the  colored  race.  The  condition  probably 
results  from  disturbed  innervation. 

Symptoms. — Milk-white  spots  appear  on  the  body  and 
grow  very  slowly ;  their  borders  usually  reveal  an  increase  of 
the  normal  pigment.  Apart  from  the  absence  of  pigment  the 
skin  is  normal. 

Diagnosis.  Moiyhoea.— The  initial  hypersemia  and  the 
subsequent  atrophy  of  the  skin  will  serve  to  distinguish 
morphoea  from  vitiligo. 

Ancesthetie  Leprosy. — The  subjective  symptoms,  the  atrophy 
of  the  tissues,  and  the  anaesthesia  will  separate  leprosy  from 
vitiligo. 

Prognosis. — Unfavorable;  the  disease  usually  persists 
through  life. 

Treatment. — Tonics  and  local  stimulants  may  be  tried. 
Among  the  latter,  electricity,  blisters,  and  irritating  ointments 
have  been  recommended. 


CANITIES — ATROPHY  OF  THE   HAIR.  459 

Definition. — Grayness  of  the  hair. 

Etiology. — Local  grayness  may  be  congenital,  or  result 
from  some  disturbance  of  innervation,  as  in  neuralgia  of  the 
supraorbital  nerve.  As  a  general  condition  it  is  usually  an 
expression  of  senility,  although  it  occasionally  develops  very 
early  in  life.  Profound  emotional  disturbances  sometimes 
induce  an  abrupt  development  of  canities. 

Prognosis. — The  condition  is  permanent,  and  treatment  is 
of  no  avail. 

ATROPHIA  CUTIS. 

Etiology. — Atrophy  of  the  skin  occurs  under  several  con- 
ditions. A  local  atrophy  may  result  from  inflammation  or 
injury  of  a  nerve-trunk  ;  in  these  cases,  the  wrinkles  are  absent, 
the  skin  is  thin,  smooth,  and  shiny,  and  there  is  often  intense 
burning  in  the  part  ("glossy  skin'^).  Atrophy  is  also  ob- 
served in  leprosy,  morphoea,  and  scleroderma. 

Universal  atrophy  of  the  skin  results  from  senility,  and 
very  rarely  as  an  idiopathic  condition.  Sometimes  the  atrophy 
occurs  in  lines  or  spots  (sti'ice  et  maculce  atrophicce)  as  an 
idiopathic  condition,  or  as  the  result  of  stretching  the  skin,  as 
in  the  liiiece  albicantes  following  pregnancy. 

ATROPHY  OF  THE  HAIR. 

Etiology. — Atrophy  of  the  hair  may  result  from  local 
diseases  which  interfere  with  the  nutrition  of  the  scalp,  such 
as  seboiThoea,  eczema,  ringworm,  etc. ;  or  it  very  rarely  arises 
as  an  idiopathic  condition  without  obvious  cause. 

Prognosis. — When  the  cause  can  be  ascertained  and  re- 
moved, the  prognosis  is  favorable. 

Treatment. — Local  diseases  will  require  appropriate  treat- 
ment. The  general  health  should  be  improved.  Stimulating 
applications  of  mercury,  sulphur,  or  carbolic  acid  are  sometimes 
useful. 


460       DISEASES   OF  THE  SKIN   AND   ITS   APPENDAGES. 


ATROPHY  OF  THE  NAEL. 

Etiology. — OccasioDally  the  condition  is  congenital,  but 
more  frequently  it  is  acquired,  and  results  from  injury  or  dis- 
ease of  the  nerve-trunk ;  from  some  general  disease,  like  one 
of  the  fevers,  syphilis,  or  cancer ;  or  from  some  disease  of  the 
skin,  as  psoriasis  or  ringworm. 

Symptoms. — The  nails  lose  their  lustre,  cease  to  grow,  and 
become  opaque  and  brittle. 

Prognosis  and  Treatment. — Both  will  depend  on  the 
exciting  cause. 

ALOPECIA. 

(Baldness.) 

Etiology. — (1)  Baldness  may  be  congenital ;  in  these  cases 
it  is  usually  partial.  (2)  It  may  be  an  expression  of  senility ; 
in  which  case  it  generally  begins  on  the  crown  or  brow,  and  is 
associated  with  more  or  less  atrophy  of  the  scalp.  (3)  It  may 
occur  early  in  life,  as  an  idiopathic  affection  arising  without 
obvious  cause.  (4)  It  may  result  from  general  diseases,  like 
syphilis  and  the  fevers.  (5)  In  early  life  it  is  often  due  to 
some  local  disease,  especially  seborrhoea. 

Prognosis. — In  congenital,  senile,  and  idiopathic  alopecia 
the  prognosis  is  unfavorable.  In  the  alopecia  of  general  dis- 
eases the  prognosis  is  usually  favorable.  In  alopecia  result- 
ing from  seborrhoea  much  can  be  accomplished  by  persistent 
and  judicious  treatment. 

Treatment. — The  general  health  should  be  improved. 
Frequent  washing  the  head  with  warm  water  and  castile  soap 
is  to  be  recommended.  One  of  the  following  local  stimulants 
may  be  prescribed :  Cantharides,  quinine,  alcohol,  capsicum, 
sulphur,  or  carbolic  acid. 

^   Quininse  sulph.,  .^ss; 
Tinct.  cantharidis,  f^j  ; 
Spt.  ammon.  arouiat.,  fgj  ; 
Ol.  ricini,  f^iss  ; 
Spt.  myrciiB,  f^vss  ; 
Ol.  rosmarini,  gtt.v.— M.     (GtERHArd.) 


Or- 


Or— 


ALOPECIA   AEEATA.  461 


^   Tinct.  cantharidis,  ^j  ; 
Acid,  carbolici,  3j  ; 
01.  ricini,  ^iss  ; 
Spt.  myrciJB, 
Spt.  lavandulse,  aa  f^ij. — M. 


^  Tinct.  cantharidis,  f^ij  ; 
Quininse  sulph.,  gr.  x  ; 
Glycerini,    f^^ss  ; 
01.  rosmarini,  gtt.  v  ; 
Spt.  myrcise,  q.  s.  ad^v. — M. 


ALOPECIA  AREATA. 

(Alopecia  Circumscripta.) 

Definition. — Baldness  appearing  in  circumscribed  patches 
without  any  obvious  lesion  of  the  skin. 

Etiology. — The  cause  is  unknown.  Some  regard  it  as  of 
parasitic  origin,  while  others  look  upon  it  as  a  neurosis.  It 
is  generally  observed  in  early  adult  life. 

Symptoms. — The  disease  is  characterized  by  the  sudden  or 
gradual  appearance  of  circumscribed  round  patches  of  bald- 
ness. At  first  there  is  no  change  in  the  appearance  of  the 
skin^  but  later  it  may  become  pale  and  atrophied.  Although 
the  scalp  is  the  most  frequent  seat,  it  occasionally  involves 
other  hairy  parts,  as  the  eyebrows,  beard,  etc. 

Diagnosis.  Ringioorm. — Ringworm  is  exceedingly  rare  in 
adults,  and  is  characterized  by  elevated  scaly  jjatches  through 
which  project  dry,  brittle,  broken  hairs.  If  there  should  be 
any  doubt  in  the  diagnosis,  the  microscope  may  be  employed 
to  detect  the  tricophyton. 

Prognosis. — In  the  majority  of  cases  the  hair  returns 
under  prolonged  and  persistent  treatment.  The  older  the 
patient  the  less  favorable  the  prognosis. 

Treatment. — General  tonics  like  iron,  arsenic,  quinine,  and 
strychnine  are  usually  indicated.  The  local  treatment  should 
be  stimulating  and  consist  in  the  application  of  blisters^  elec- 


) 


462       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

tricity,  friction,  rubefacient  liniments,  or  ointments  containing 
chrysarobin,  tar,  sulphur,  or  ammoniated  mercury. 

^   Tinct.  cautharidis, 

Tinct.  capsici,  aa  f^iss  ; 
Olei  riciui,  fgij  ; 
Alcoholis,  f^vj  ; 
Spts,  rosmarini,  fgij. — M. 

(DuHRiNG  and  Stel wagon.) 


Or— 
Or— 


^.  Acid,  chrysophanic,  3iss; 
Adipis,  Sij-— M. 

^  Sulphur,  loti,  ^iv  ; 
01.  cadini,  ^ij  ; 
Adipis,  gj. — M. 

SYCOSIS. 

(Simple  Sycosis,  Folliculitis  Barbae.) 

Definition. — A  non-contagious  inflammatory  disease  of 
the  hair-follicles. 

Etiology. — The  affection  probably  results  from  local  irri- 
tation. 

Symptoms. — The  disease  usually  manifests  itself  on  the 
bearded  region  of  the  face,  and  is  characterized  by  an  aggre- 
gation of  papules  and  pustules,  each  of  which  is  pierced  by  a 
hair.  When  the  lesions  are  discrete  the  intervening  skin  is 
often  quite  healthy ;  but  when  they  are  close  together  it  is 
often  infiltrated  and  hypersemic.  During  the  papular  stage 
the  hairs  are  not  loose,  but  firmly  attached ;  during  the  pus- 
tular stage,  however,  they  can  be  readily  extracted.  The 
pustules  show  no  tendency  to  rupture,  but  dry  to  yellowish- 
brown  crusts.  Acute  cases  are  associated  with  more  or  less 
burning  and  itching.  If  the  disease  persists,  it  may  lead  to 
extreme  destruction  of  the  hair-follicles  and,  as  a  consequence, 
to  permanent  alopecia. 

Diagnosis.  Eczema. — The  lesions  in  eczema  are  not  dis- 
crete, are  not  perforated  by  hairs,  and  are  not  confined  to  the 
hairy  parts. 

Tinea  Sycosis^  or  Barber's  Itch. — The  affection  begins  as  a 


POMPHOLYX.  463 

red  scaly  patch,  and  is  followed  by  the  development  of  large, 
deeply-seated  tubercles.  The  hairs  soon  become  dry,  brittle, 
and  broken  off,  and  can  be  easily  extracted.  In  doubtful 
cases  the  microscope  may  be  employed  for  the  detection  of  the 
tricophyton. 

Prognosis. — The  disease  is  curable  under  prolonged  and 
judicious  treatment.     Relapses  are  very  prone  to  occur. 

Treatment. — In  acute  cases  soothing  applications  are  in- 
dicated ;  thus  the  parts  may  be  dabbed  with  black  wash  or 
a  saturated  solution  of  boric  acid,  and  subsequently  spread 
with  oxide  of  zinc  ointment.  In  chronic  cases  the  crusts 
should  be  removed,  and  the  hairs  cut  close  or  preferably, 
shaved.  It  is  advisable  to  puncture  the  pustules  and  to  ex- 
tract the  hairs,  so  as  to  preserve  the  follicles.  When  the  parts 
are  not  irritable  stimulating  applications  are  useful,  and  one 
of  the  following  may  be  selected  : — 

^.  Sulphur,  prsecip.,  ^ij  ; 
Ung.  aquse  rosse,  ^j. — M. 
Sig. — Apply  twice  daily. 

Or— 

J^:.   Ung.  diachyli, 

Ung.  zinc,  oxidi,  aa  giss  ; 
Ung.  hydrarg.  ammon.,  ^iij  ; 
Bismuth,  subnitratis,  ^iss. — M.     (Kobinson.) 
Sig, — Apply  twice  daily. 

Or— 

^  Ichthyol.,  5j  ; 
Uug.  diachyli,  ^j  ; 
Sig. — Apply  twice  daily. 

POMPHOLYX. 

(Dysidrosis.) 

Pompholyx  is  a  very  rare  disease,  usually  observed  in  those 
who  perspire  freely,  and  characterized  by  an  eruption  of 
deeply-seated  vesicles  which  resemble  sago-grains  imbedded 
in  the  skin.  The  vesicles  most  commonly  appear  on  the  hands, 
especially  between  the  fingers,  and  gradually  increase  in  size 


464       DISEASES  OF  THE  SKIN  AND   ITS  APPENDAGES. 

until  they  reach  the  dimensious  of  blebs.  They  show  no 
tendency  to  rupture,  but  dry  up,  and  are  followed  by  exten- 
sive desquamation  of  the  cuticle.  The  eruption  often  excites 
considerable  pain  and  tenderness.  The  disease  usually  dis- 
appears in  the  course  of  a  few  weeks,  but  is  prone  to  recur. 

Treatment. — General  tonics  like  iron,  strychnine,  and 
arsenic  are  often  indicated.  Locally,  sedative  lotions  or  oint- 
ments should  be  employed. 

loENTIGO. 

(Freckle.) 

Definition. — A  deposition  of  pigment  in  the  form  of 
small,  irregular-shaped  brownish  spots. 

Etiology. — Blondes  are  more  subject  to  the  aifection  than 
brunettes.  Exposure  to  the  sun's  rays  often  serves  as  an 
exciting  cause. 

Symptoms. — Exposed  parts — the  face,  shoulders,  arras,  and 
hands — ^are  mostly  affected.  The  patches  vary  in  color  from 
yellow  to  dark  brown,  and  range  in  size  from  a  pin-head  to  a 
pea. 

Prognosis. — Freckles  can  be  removed,  but  they  always 
return. 

Treatment. — One  of  the  best  remedies  is  the  bichloride  of 
mercury  in  solution  or  ointment. 

^  Hydrarg.  chlor.  corros.,  gr.  iv  ; 
Alcohol,  et  aquse,  aa  ad  :§iv. — M. 
Sig. — Apply  twice  daily. 

CHLOASMA. 

Definition. — An  abnormal-  deposition  of  pigment  in  the 
form  of  large  brown  or  liver-colored  patches. 

Etiology. — It  may  result  from  the  application  of  external 
irritants ;  from  general  diseases  like  malaria  and  Addison's 
disease;  or  from  affections  of  the  uterus,  as  pregnancy, 
tumors,  etc. 

Symptoms. — The  affection  consists  in  the  appearance — 
especially  on  the  face — of  large,  round,  or  irregular-shaped 


KERATOSIS   PILARIS.  465 

brownish  or  blackish  patches.     Apart  from  the  discoloration 
the  skin  is  normal. 

Diagnosis. — In  Leueoderma  the  periphery  of  the  patches 
is  pigmented,  but  the  central  milk-white  appearance  is  not 
seen  in  chloasma. 

Prognosis. — When  the  cause  can  be  removed  the  prog- 
nosis is  favorable. 

Treatment. — When  possible  the  cause  should  be  removed. 
The  best  local  remedies  are  bichloride  of  mercury  and  sul- 
phur. 

1^:  Zinci  oxidi,  gr.  iij  ; 

Hydrarg.  ammoniat.,  gr.  iss ; 
01.  theobrom., 
01.  ricini,  aa  giiss  ; 

Essent.  rosse,  gtt,  x.— M.     (Monin.) 
Sig. — Apply  to  the  face  night  and  morning. 

KERATOSIS  PILARIS. 

(Lichen  Pilaris.) 

Definition. — Small,  papular  elevations  resulting  from 
hypertrophy  of  the  epidermis  surrounding  the  outlets  of  the 
hair-follicles. 

Etiology. — It  generally  results  from  infrequent  bathing. 

Symptoms. — The  skin,  particularly  on  the  extensor  sur- 
faces of  the  arms  and  legs,  is  the  seat  of  numerous  pin-head 
elevations,  which  have  a  dirty-gray  color  and  are  pierced  by 
hairs.  It  may  excite  some  itching.  Generally  there  are  no 
evidences  of  inflammation,  but  sometimes  a  few  red  papules 
or  even  pustules  result  from  irritation. 

Diagnosis. — In  Cutis  Anserina,  or  goose-flesh,  the  lesions 
are  transient  and  have  the  color  of  normal  skin. 

Prognosis. — Favorable. 

Treatment. — In  most  cases  nothing  will  be  required  be- 
yond frequent  bathing  with  soap,  followed  by  friction  of  the 
skin.  In  obstinate  cases  some  simple  ointment  may  be  ap- 
plied after  bathing. 

30 


466       DISEASES  OF  THE  SKIN   AND   ITS  APPENDAGES. 

MOIiLUSCUM  EPITHELIAI.E. 

(Molluscum  Contagiosum,  MoUuscum  Sebaceum.) 

Definition. — A  cutaneous  affection,  characterized  by  the 
appearance  of  discrete  wax -like  elevations  ranging  in  size  from 
a  pin-head  to  a  pea,  and  varying  in  color  from  white  to  rose- 
pink. 

Etiology. — The  disease  is  generally  observed  in  children, 
and  frequently  affects  several  members  of  the  same  household, 
school,  or  asylum.     It  is  probably  contagious. 

Symptoms. — Small  white  or  pale-pink,  wax-like  elevations 
appear,  especially  on  the  face.  They  are  always  discrete  and 
rarely  abundant.  The  centre  of  the  elevation  is  depressed 
and  reveals  a  dark  spot  which  corresponds  to  the  aperture  of 
the  follicle.  At  first  the  lesions  are  quite  firm,  but  as  they 
grow  old  they  become  soft.  When  firmly  squeezed  they 
exude  a  soft,  cheesy  material.  Afiber  remaining  for  several 
weeks  they  break  down  or  undergo  slow  absorption. 

Diagnosis. — The  color,  the  wax-like  appearance,  the  um- 
bilication,  and  the  central  aperture  are  the  diagnostic  features. 

Prognosis. — Favorable,  although  the  disease  may  run  a 
protracted  course  of  months  or  years. 

Treatment. — General  tonics  like  iron,  strychnine,  and 
arsenic  are  often  indicated.  The  lesions  should  be  incised, 
the  contents  expressed,  and  their  bases  touched  with  nitrate  of 
silver ;  ointments  of  mercury  and  sulphur  have  also  been  rec- 
om-mended. 

CALLOSITAS. 

(Callus,  Keratoma,  Tylosis.) 

Definition. — A  thickened,  horny  condition  of  the  skin 
resulting  from  hypertrophy  of  the  corneous  layer  of  the  epi- 
dermis. 

Etiology. — Constant  irritation  from  friction  or  pressure  is 
the  chief  cause ;  hence  it  is  frequently  seen  on  the  feet  from 
the  rubbing  of  shoes,  and  on  the  hands  from  the  friction  of 
tools. 


CLAvus.  *  467 

Symptoms. — The  condition  is  characterized  by  the  gradual 
appearance  of  hard,  thickened,  grayish  masses,  which  gradu- 
ally merge  into  healthy  skin.  The  soles  and  palms  are  the 
parts  most  frequently  affected.  When  slight  it  causes  little 
inconvenience,  but  occasionally  it  becomes  fissured  and  pain- 
ful. 

Prognosis. — It  yields  rapidly  to  treatment  when  the  cause 
is  removed. 

Treatment. — When  excessive  the  parts  should  be  soaked 
and  the  thickened  epidermis  pared  off.  One  of  the  best  reme- 
dies for  softening  the  horny  overgrowth  is  salicylic  acid ;  it 
may  be  applied  in  the  form  of  a  plaster  or  in  collodion. 

^   Acid,  salicylic,  3j  ; 
Collodii,  f^j.— M. 
Sig. — Apply  night  and  morning. 

CLAVUS. 

(Com.) 

Definition. — Clavus  is  a  circumscribed  thickening  of  the 
epidermis  usually  appearing  on  the  feet. 

Etiology. — Corns  generally  result  from  the  friction  of  ill- 
fitting  shoes. 

Symptoms. — Small,  circumscribed,  horny  elevations  appear 
upon  the  feet  and  often  excite  severe  pain.  When  bathed  in 
perspiration  they  become  more  or  less  macerated,  and  in  this 
condition  constitute  the  so-called  soft  corn. 

Treatment. — A  radical  cure  requires  the  use  of  well- 
fitting  shoes.  The  corns  may  be  removed  by  soaking,  paring, 
and  the  application  of  some  mild  caustic  like  salicylic  acid. 

^  Acid,  salicylic. ,  gr.  xxx  ; 
Tinct.  iodi,  tt\^x; 
Ext.  cannabis  ind.,  gr.  x  ; 
Collodii,  f|ss.— M. 
Sig. — Apply  night  and  morning  for  several  days,  and  then  soak 
in  hot  water. 


468       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

CORNU  CUTAJfEUM. 

(Cutaneous  Horn.) 

Definition. — A  circumscribed,  projecting  outgrowth  re- 
sulting from  hy})ertrophy  of  the  epidermis. 

Symptoms. — Horns  generally  appear  on  the  face,  scalp,  or 
penis,  and  are  usually  observed  in  the  old.  They  consist  of 
dry,  rough,  horny,  more  or  less  conical  projections,  which  vary 
in  length  from  a  few  lines  to  several  inches. 

Prognosis. — Favorable. 

Treatment. — The  horn  should  be  excised  and  the  base 
subsequently  cauterized. 

VERRUCA. 

(•Wart.) 

Definition. — A  wart  is  a  circumscribed  elevation  result- 
ing from  hypertrophy  of  the  papillae  and  epidermis. 

Etiology. — The  cause  is  obscure.  A  bacterial  origin  has 
been  suggested.  They  are  most  frequently  observed  in 
children. 

Symptoms. —  Verruca  Vulgaris,  or  common  wart,  is  gener- 
ally observed  on  the  hands  of  children.  It  consists  of  a  firm, 
circumscribed  elevation,  varying  in  size  from  a  millet-seed  to 
a  pea. 

Ven'uca  plana,  or  flat  wart,  is  a  circumscribed,  flat,  pig- 
mented elevation  usually  observed  on  the  backs  of  old  people. 

Verruca  Filiformis. — This  is  a  thread-like  overgrowth,  and 
is  generally  observed  on  the  soft  parts,  like  the  face  and  neck. 

VetTuca  Digitata. — This  form  is  made  up  of  numerous 
branches,  and  is  generally  observed  on  the  scalp. 

Verucca  Acuminata,  or  Venereal  Wart. — This  appears  in 
groups  about  the  genitalia.  It  is  soft,  red  in  color,  and  highly 
vascular.  It  may  be  dry  or  moist  according  to  its  location  ; 
the  latter  condition  often  gives  rise  to  a  peculiarly  ofiensive 
odor. 

Treatment. — Ordinary  warts  may  be  removed  by  ex- 
cision, caustics,  or  electrolysis. 


ICHTHYOSIS.  469 

.Venereal  warts  should  be  bathed  in  some  antiseptic  solution 
and  subsequently  dusted  with  calomel,  iodoform,  or  boric  acid. 

NiEVUS  PIGJ^IENTOSUS. 

(Mole.) 

Definition. — A  circumscribed  deposit  of  pigment,  usually 
associated  with  hypertrophy  of  cutaneous  structures. 

Etiology. — Moles  are  usually  congenital. 

Symptoms. — The  neck,  face,  and  trunk  are  favorite  locali- 
ties. The  nsevi  vary  in  number  from  one  to  several  hundred  ; 
in  size,  from  a  millet-seed  to  a  filbert ;  and  in  color,  from  yel- 
low to  black.  When  the  surface  is  smooth,  the  growth  is 
termed  ncevus  spilus  ;  when  the  surface  is  covered  with  hair,  it 
is  termed  ncevus  pilosus ;  when  the  surface  is  warty,  it  is 
termed  ncevus  verrucosus  ;  and  when  there  is  much  overgrowth 
of  connective  tissue,  it  is  termed  ncevus  Upomatodes. 

Treatment. — They  may  be  removed  by  excision,  the  ap- 
lication  of  caustics,  or  by  electrolysis. 

ICHTHYOSIS. 

(Fish-skin  Disease.) 

Definition. — A  chronic  affection  characterized  by  dryness, 
thickening  of  the  epidermis,  and  scaliness. 

Etiology. — The  affection  is  often  hereditary  and  is  usually 
detected  in  early  childhood. 

Symptoms.  —  The  skin  is  dry  and  harsh ;  the  surface  is 
covered  with  adherent  polygonal  scales ;  and  the  papillae  are 
more  or  less  hypertrophied.  The  term  Ichthyosis  hystrix  is 
applied  to  the  condition  when  there  is  excessive  hypertrophy 
of  the  papillae.  The  extensor  surfaces  of  the  extremities  are 
the  parts  most  involved. 

Diagnosis. — The  absence  of  all  inflammatory  symptoms 
will  separate  ichthyosis  from  squamous  eczema  and  psoriasis. 

Prognosis. — The  disease  is  incurable ;  but  the  patient  can 
be  rendered  comfortable  by  appropriate  treatment. 


470       DISEASES   OF   THE   SKIN    AND    ITS   APPENDAGES. 

Treatment. — The  scales  may  be  removed  by  alkaline 
baths  or  by  applications  of  green  soap.  The  skin  may  be 
rendered  pliable  by  rubbing  in  some  simple  ointment. 

^  Sulpliuris,  gr.  xxv-1 ; 

Ung.  simp.,  gj.— M.     (Unna.) 
Sig. — Rub  in  at  night. 

ONYCHAUXIS. 

/  Onychauxis,  or  hypertrophy  of  the  nail,  may  be  congenital, 
or  may  result  from  certain  skin  affections,  such  as  eczema, 
ringworm,  or  syphilis ;  from  diseases  of  the  nerves,  as  neuritis ; 
or  from  traumatism. 

^  HYPERTRICHOSIS. 

(Hirsuties.) 

Hypertrichosis,  or  hypertrophy  of  the  hair,  may  be  local  or 
general.  The  term  is  applied  not  only  to  an  excessive  over- 
growth of  hair,  but  to  a  growth  of  hair  in  unusual  localities,  as 
on  the  faces  of  young  women. 

Treatment. — The  hair  may  be  removed  temporarily  by 
shaving,  epilation,  or  depilatories.  Permanent  relief  can  only 
be  accomplished  by  electrolysis. 

SCLERODERMA. 

(Sclerema,  Scleriasis.) 

I  Definition. — A  pigmented,  rigid,  indurated  condition  of 
•^the  skin,  occurring  in  circumscribed  patches  or  involving  the 
entire  body. 

Etiology. — The  cause  is  unknown. 

Symptoms. — The  affection  may  be  diffuse  or  involve  cir- 
cumscribed patches.  It  may  appear  quite  suddenly,  or  develop 
very  gradually  in  the  course  of  months  or  years.  The  skin 
assumes  a  yellowish-brown  color,  becomes  rigid,  indurated, 
and  hide-bound ;  the  surface  is  unnaturally  dry  and  smooth. 
When  the  condition  is  advanced  the  joints  become  more  or 
less  immobile. 


MORPHCEA — ELEPHANTIASIS.  471 

Prognosis.  —  Guarded.  It  often  recovers  spontaneously- 
after  having  persisted  for  a  long  time.  In  other  cases  the  pro- 
cess may  spread  until  the  patient  becomes  almost  helpless. 

Treatment. — Tonics  like  iron,  arsenic,  and  cod-liver  oil 
are  often  indicated.  Locally,  massage,  friction,  electricity, 
and  inunctions  are  recommended. 

MORPHGEA. 

(Addison's  Keloid.) 

/  Definition. — A  cutaneous  affection,  characterized  by  cir- 
cumscribed, rounded,  ivory-like  patches,  which  have  hypersemic 
or  pigmented  borders. 

Etiology. — The  cause  is  unknown.  It  is  generally  re- 
garded as  a  circumscribed  form  of  leucoderma. 

Symptoms. — The  lesions  usually  appear  upon  the  trunk 
and  consist  of  sharply-circumscribed  patches,  which  are  at 
first  slightly  hypersemic.  The  surface  is  smooth  and  resistant 
to  the  touch.  As  the  patch  grows  old  its  centre  becomes  pale 
and  ivory-like,  while  the  periphery  remains  hypersemic  or  be- 
comes pigmented. 

Prognosis. — Guarded. 

Treatment. — The  same  as  scleroderma. 


ELEPHANTIASIS. 

(Elephantiasis   Arabum,    Elephantiasis    Pachydermia,   Barbadoes 

Leg.) 

Definition. — Hypertrophy  of  the  skin  and  subcutaneous 
tissues,  usually  associated  with  lymphangitis,  oedema,  and  pig- 
mentation. 

Etiology. — While  elephantiasis  may  occur  in  any  part  of 
the  world,  it  is  far  more  common  in  the  tropics.  It  is  most 
frequently  observed  in  the  male  sex,  and  rarely  develops 
before  adult  life.  It  results  from  obstruction  of  the  lym- 
phatics, and  the  most  common  cause  of  such  obstruction  is  the 
presence  of  a  parasite — -filaria  sanguinis  hominis. 


472       DISEASES   OP  THE   SKIN   AND   ITS   APPENDAGES. 

Pathology. — Examination  of  the  affected  tissues  reveals 
hypertrophy  of  the  connective  tissue,  oedema,  and  inflamma- 
tion and  dilatation  of  the  lymphatic  vessels. 

Symptoms. — It  usually  begins  with  recurring  attacks  of 
erysipelatoid  inflammation.  The  part  is  red,  swollen,  and 
painful ;  the  lymphatics  may  be  traced  as  brandling  red  lines 
beneath  the  skin ;  and  with  these  local  phenomena  there  is 
more  or  less  fever.  After  each  attack  the  part  is  left  a  little 
enlarged,  until  finally  it  presents  the  following  characteristic 
appearance :  it  is  enormously  swollen  ;  the  skin  is  thickened, 
roughened,  and  pigmented ;  and  the  papillse  are  unusually 
prominent.  The  regions  generally  affected  are  the  legs  and 
genitals.  In  elephantiasis  of  the  scrotum  (lymj^h-scrotum)  the 
hypertrophied  mass  may  weigh  as  much  as  fifty  or  even  a 
hundred  pounds. 

Prognosis. — In  the  early  stage  the  disease  may  be  arrested, 
but  when  fully  established  it  is  incurable. 

Treatment. — The  acute  inflammatory  attacks  should  be 
treated  by  rest  and  the  application  of  sedative  lotions,  like 
lead-water  and  laudanum.  Subsequently  mercurial  inunc- 
tions may  be  employed,  and  the  part  firmly  bandaged  with 
the  view  of  promoting  absorption.  Amputation  may  be  suc- 
cessfully employed  in  lymph-scrotum.  In  elephantiasis  of 
the  limbs  ligation  of  the  main  artery  has  given  somewhat 
encouraging  success.  More  recently  galvanism  has  given  very 
good  results. 

DERMATOLYSIS. 

(Pachydermatocele,  Cutis  Pendula.) 

Definition. — A  circumscribed  liypertrophy  of  the  skin 
and  subcutaneous  tissues  resulting  in  a  softened  and  pendulous 
condition  of  the  integument. 

Symptoms. — The  part  affected  is  thickened  and  pigmented  ; 
it  is  soft  and  fat-like  to  the  touch  ;  and  when  the  condition  is 
marked,  the  skin  hangs  in  folds.  The  regions  generally 
affected  are  the  shoulders,  arms,  back,  and  buttocks. 

Treatment. — The  redundant  tissue  may  be  removed  by 
excision  or  electrolysis. 


KELOID— FIBROMA.  473 

KELOID. 

(Cheloid,  Kelis.) 

Definition. — A  new  growth  resulting  from  hypertrophy  of 
the  connective  tissue  of  the  corium. 

Etiology. — It  generally  results  from  local  injury,  though 
it  is  claimed  that  it  may  arise  spontaneously.  Certain  fami- 
lies and  individuals  are  especially  predisposed.  It  is  more 
frequent  in  the  colored  race. 

Symptoms. — It  begins  as  a  pale-red  nodule,  which  slowly 
increases  in  size  and  sends  out  claw-like  processes.  From  its 
resemblance  to  a  crab  it  has  been  termed  keloid.  It  is  firm, 
elastic,  slightly  elevated,  sharply  defined,  and  ranges  in  size 
from  a  small  bean  to  a  growth  as  large  as  the  hand.  It 
sometimes  excites  pain  and  itching,  but  generally  subjective 
phenomena  are  absent.  The  regions  most  frequently  involved 
are  the  chest  and  back. 

Diagnosis. — Keloid  may  be  distinguished  from  a  hyper- 
tropMed  scar  by  the  fact  that  the  latter  does  not  extend  beyond 
the  limits  of  the  injury. 

Prognosis. — The  growth  is  usually  permanent,  and  after 
removal  invariably  returns. 

Treatment. — It  may  be  removed  temporarily  by  excision, 
electrolysis,  or  caustic  pastes. 

FIBROMA. 

(Molluscum  Pibrosum.) 

Definition. — A  circumscribed  overgrowth  derived  from 
the  subcutaneous  connective  tissue. 

Etiology — Early  life  and  heredity  are  predisposing  factors. 

Symptoms — The  tumors  are  circumscribed  ;  painless  ;  soft 
or  firm  ;  often  multiple ;  range  in  size  from  a  pea  to  a  hen's 
egg ;  and  do  not  impair  the  general  health.  The  overlying 
skin  may  be  normal  in  appearance  or  slightly  hypersemic. 

Prognosis. — They  are  permanent  and  treatment  is  rarely 
indicated. 


4:74       DISEASES   OF   THE  SKIN   AND   ITS  APPENDAGES. 

ANGIOMA. 

(Naevus  Vasculosus.) 

Definition. — A  new  growth^  composed  of  cavernous  tissue, 
or  a  congeries  of  small  bloodvessels. 

Angioma  Cavernosum. — This  form  is  congenital,  is  com- 
posed of  cavernous  tissue,  and  appears  as  a  circumscribed, 
elevated,  dark-red  tumor,  which  ranges  in  size  from  a  pea  to 
one  as  large  as  the  hand.     It  is  often  lobulated  and  pulsating. 

Angioma  Simplex  {Capillary  Nwvus, Port-wine  3Iark). — This 
form  is  also  congenital,  and  is  composed  of  a  congeries  of  ca- 
pillaries. It  is  non-elevated,  bright-red  or  purple-red  in 
color,  and  may  cover  an  area  of  several  inches.  It  is  gener- 
ally found  on  the  face,  and  constitutes  what  is  popularly 
termed  a  mother's  mark. 

Telangiectasis. — This  form  is  acquired,  and  is  composed  of 
dilated  or  newly-developed  capillaries.  It  appears  as  a  bright- 
red  dot  from  which  branch  dilated  capillaries.  It  is  fre- 
quently associated  with  acne  rosacse ;  it  is  also  common  in 
those  of  a  gouty  diathesis  and  in  those  much  exposed  to  the 
weather. 

Treatment. — Cavernous  angiomata  may  be  removed  by 
ligation,  excision,  or  electrolysis.  Simple  angiomata  and  telan- 
giectasis are  best  treated  by  electrolysis. 

XANTHOMA. 

(Vitiligoidea,  Xanthelasma.) 

Definition.  —  A  circumscribed  connective-tissue  new- 
growth  appearing  as  flat  patches  or  tubercles  of  a  yellowish 
color. 

Etiology.' — Middle  life  and  female  sex  are  general  pre- 
disposing factors.  Hepatic  disorders,  especially  obstructive 
jaundice,  seem  to  exert  a  decided  predisposing  influence. 

Symptoms. — There  are  two  forms :  Xanthoma  planum, 
which  generally  appears  about  the  eyelids  and  consists  of 
smooth,  circumscribed,  slightly  elevated,  buff-colored  patches ; 
and  Xanthoma  tuberosum,  which  may  appear  on  the  neck, 


LUPUS   EEYTHEMATOSUS.  475 

shoulders,  trunk,  or  extremities,  and  consists  of  small,  elastic, 
and  yellowish-colored  nodules. 

Treatment. — These  growths  may  be  removed  by  excision, 
electrolysis,  or  caustics. 

LUPUS  ERYTHEl^IATOSUS. 

(Seborrhcea  Congestiva.) 

DefijSTITION — Lupus  erythematosus  is  a  new-growth  result- 
ing from  a  cellular  infiltration  of  the  skin,  and  characterized 
by  circumscribed,  red  patches  which  are  more  or  less  covered 
with  yellowish-gray  adherent  scales. 

Etiology. — Middle  life  and  female  sex  are  predisposing 
factors.  It  frequently  arises  from  disorders  of  the  sebaceous 
glands,  as  seborrhcea  or  acne. 

Pathology. — By  many  it  is  regarded  as  a  chronic  derma- 
titis which  originates  in  the  sebaceous  glands. 

Symptoms. — The  disease  usually  manifests  itself  on  the 
face,  in  the  region  of  the  nose,  and  appears  as  small,  red, 
slightly  elevated  papules,  which  are  more  or  less  scaly.  An 
erythematous  patch  is  gradually  formed  by  the  coalescence  of 
these  pajjules.  The  periphery  of  the  patch  is  elevated  and 
sharply  defined,  while  the  centre  is  depressed  and  atrophied. 
The  ducts  of  the  sebaceous  glands  are  dilated  and  often  filled 
with  sebum.  The  disease  spreads  very  slowly,  shows  no  ten- 
dency to  ulceration,  and  rarely  excites  any  subjective  symptoms. 

Diagnosis. — The  location,  the  sharply-defined  red  patch 
with  an  elevated  margin  and  depressed  centre,  the  slight  scali- 
ness,  the  dilated  sebaceous  ducts,  the  chronic  coui^e,  and  the 
absence  of  ulceration  are  the  diagnostic  features. 

Lupus  Vulgaris. — This  affection  begins  earlier  in  life,  is 
characterized  by  tubercles  and  ulceration,  and  lacks  involve- 
ment of  the  sebaceous  glands. 

Peognosis. — Favorable  under  prolonged  and  judicious 
treatment. 

Treatment. — General  tonics  like  iron,  arsenic,  phos- 
phorus, and  cod-liver  oil  are  often  indicated. 

Local  Treatment. — In  many  cases  mild  applications 
accomplish  the  most  good.     Much   benefit  is  often  derived 


476        DISEASES   OF   THE   SKIN    AND   ITS   APPENDAGES. 

from  washing  the  part  thoroughly  with  green-soap  and  alcohol 
for  a  few  days  and  then  applying  the  following  lotion  : — 

^   Zinc,  sulphatis, 

Potassi  sulphidi,  aa  ^ij  ; 
Aqufe,  fsiij  ; 

Alcoholis,  fgj. — M.     (Dtjhring.) 
Sig. — Shake  well,  dab  the  parts  for  fifteen  minutes  twice  daily, 
and  allow  to  dry  on. 

In  sluggish  cases  stimulating  applications  are  useful,  and 
one  of  the  following  may  be  selected  : — 

^  Acid,  salicyl.,  3SS  ; 
Acid,  lactic,  ^ss ; 
Resorcin.,  gr.  xlv ; 
Zinc,  oxid.,  gij  ; 
Vaselin.  pur.,'3xvij. — M.     (Broca.) 

Or— 

^   Acidi  pyrogallici,  ^j  ; 

Cerati,  ^ix. — M.     (Kaposi.) 
Sig. — Apply  locally. 

In  obstinate  cases,  scarification,  curetting,  or  burning  with 
the  galvano-cautery  may  be  employed  with  advantage. 

LUPUS  VULGAKIS. 

(Lupus  Exedens.) 

Definition. — A  local  manifestation  of  tuberculosis,  char- 
acterized by  soft  red  tubercles,  which  usually  terminate  in  ul- 
ceration and  scarring. 

Etiology. — Early  life  and  female  sex  are  general  pre- 
disposing factors.  It  is  comparatively  rare  in  this  country, 
but  very  common  in  Austria  and  Germany.  The  exciting 
cause  is  the  tubercle  bacillus. 

Symptoms. — Lupus  vulgaris  most  frequently  manifests  it- 
self on  the  face,  especially  near  the  nose.  It  begins  as  minute, 
deeply-seated,  reddish-brown  papules,  wdiich  grow  very  slowly 
until  they  reach  the  dimensions  of  tubercles.  They  are  smooth, 
quite  soft,  and  seldom  painful.  At  this  stage  they  may  either 
undergo  slow  absorption  or,  which  is  more  frequent,  break  down 
and  leave  chronic  ulcers.     The  ulcers  are  shallow,  and  their 


LUPUS   VULGARIS.  477 

edges  are  soft  and  red.  There  is  very  little  discharge.  They 
spread  slowly,  and  may  involve  all  the  soft  parts,  but  the  bone 
is  never  invaded.  While  one  part  of  the  ulcer  is  sjjreading, 
other  parts  are  being  filled  with  shrivelled  cicatricial  tissue 
which  in  turn  is  often  the  seat  of  new  tuberculous  nodules. 

Diagnosis.  JEpithelioma. — Epithelioma  is  a  disease  of  ad- 
vanced life ;  it  begins  as  a  firm,  wax-like  nodule ;  the  resulting 
ulcer  starts  from  a  single  point ;  its  borders  are  distinctly  ele- 
vated and  hard ;  it  secretes  a  blood-streaked  fluid ;  and  it  is 
often  painful. 

Syphilis — The  age,  history,  associated  evidences  of  syphilis, 
the  rapid  course,  the  deep  ulcers,  the  abundant  offensive  dis- 
charge, and  later  the  involvement  of  the  bones,  are  the  diag- 
nostic features. 

Prognosis. — Very  guarded.  Its  removal  is  often  followed 
by  relapse. 

Treatment. — General  tonics  like  iron,  arsenic,  phos- 
phorus, and  cod-liver  oil  are  usually  indicated. 

Local  Treatment. — The  growth  may  be  removed  by  cauter- 
ization, curetting,  excision,  or  electrolysis.  One  of  the  fol- 
lowing caustic  applications  may  be  employed  : — 

^  Acid,  arsenosi,  9j  ; 

Hydrarg.  sulphuret.  rub,,  3j  ; 
Ung.  simplicis,  ^j. — M.     (Hebra.) 
Sig. — Spread  thick  on  cloth,  and  apply  to  the  patch  for  two  or 
three  days,  until  lupus  nodules  and  points  are  blackish  or  destroyed. 

Or— 

^  Acid,  lactic,  puri,  f^. — M.     (Wichmanx.) 
Sig. — Soak  a  pledget  of  absorbent  cotton  and  apply  to  the  ulcer. 
Cover  with  oil-silk  and  bandage.  Protect  normal  tissue  with  grease. 

Or— 

^i  Acid,  salycilic,  ^ij  ; 
Adipis  benzoat.,  5j. — M. 
Sig. — Apply  locally. 

Often  the  best  results  are  obtained  by  curetting  aud  subse- 
quently applying  caustics. 

Koch's  tuberculin  has  lately  been  employed  extensively  in 
the  treatment  of  lupus,  but  it  has  not  given  such  good  results 
as  were  expected.     After  its  use  most  cases  improve,  many 


478       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

relapse,  a  few  recover.      It  seems  best  adapted  to  rapidly- 
spreading  forms  of  lupus. 

SYPHILIS  CUTA^^A. 

The  secondary  symptoms  appear  between  the  first  and  fourth 
month  following  the  chancre,  and  are  characterized  by  a  sym- 
metrical arrangement,  a  coppery  color,  polymorphism  (many 
forms  at  the  same  time),  and  an  absence  of  itching.  They  are 
usually  associated  with  certain  general  symptoms,  such  as  sore 
throat,  pain  in  the  bones,  loss  of  hair,  enlargement  of  the 
lymphatic  glands,  and  failure  of  health. 

The  tertiary  symptoms  appear  in  from  six  months  to  several 
years  after  the  primary  sore.  They  are  as  a  rule  localized, 
are  tubercular,  gummatous,  or  ulcerative  in  form,  and  tend  to 
group. 

Macular  SypMloderm. — This  is  a  secondary  manifestation, 
and  consists  in  a  general  eruption  of  dark-red  macules,  vary- 
ing in  size  from  a  millet-seed  to  a  ten-cent  piece. 

Diagnosis.  Ileasles. — The  absence  of  fever,  of  catarrh,  of 
a  crescentic  arrangement,  together  with  the  history,  will  pre- 
vent an  error  in  diagnosis. 

Papular  Syphiloderm. — This  may  be  an  early  or  late  mani- 
festation, and  is  characterized  by  a  general  eruption  of  large 
or  small,  dull-red  papules.  A  few  pustules  are  also  frequently 
present.  It  pursues  a  chronic  course,  finally  disappearing  by 
desquamation,  and  leaving  behind  slight  pigmentation. 

Diagnosis. — The  history,  distribution,  dark  color,  and  the 
presence  of  pustules  will  separate  it  from  keratosis  pilaris, 
papular  eczema,  and  lichen  ruber. 

Tuberculous  Syphiloderm. — A  late  manifestation,  charac- 
terized by  a  localized  eruption  of  dark-red  shiny  papules 
varying  in  size  from  a  pea  to  a  large  bean.  By  some  these 
tubercles  are  regarded  as  gummatous  in  character.  They  pur- 
sue a  chronic  course  and  finally  disappear  by  absorption  or 
ulceration.  The  ulcers  thus  formed,  when  single,  are  round, 
punched  out,  and  frequently  covered  with  crusts ;  when  they 
coalesce,  they  form  a  serpiginous  sore  which  pours  forth  a  thick 
yellowish  discharge. 


SYPHILIS   CUTANEA.  479 

Diagnosis.  Lwpus  Vulgaris. — This  occurs  in  earlier  life ; 
it  pursues  an  extremely  chronic  course ;  the  ulcer  is  superficial ; 
the  tubercles  are  soft,  and  frequently  redevelop  in  the  scar  tis- 
sue ;  the  secretion  is  scant ;  and  the  bone  is  never  involved. 

Epithelioma. — In  this  affection  the  progress  is  slower  ;  there 
is  only  one  point  of  ulceration ;  the  secretion  is  scanty ;  and 
the  border  is  markedly  infiltrated. 

Bullous  SypMloderm. — This  is  a  late  manifestation,  and  is 
characterized  by  an  eruption  of  well-filled  blebs  varying  in  size 
from  acofiee-bean  toa  walnut.  The  contents  of  the  blebs  are  puri- 
form.  They  subsequently  form  dark,  conical,  stratified  crusts 
under  which  are  ulcers  pouring  forth  a  thick,  purulent  fluid. 

Diagnosis.  Pemphigus. — The  history,  the  concomitant 
symptoms  of  syphilis,  and  thick,  greenish  crusts  will  serve  to 
distinguish  syphilis  from  pemphigus. 

Gummatous  SypMloderm. — This  appears  as  a  firm,  circum- 
scribed nodule  which  gradually  turns  red  and  softens.  It 
may  disappear  by  absorption,  or  break  down  and  leave  a  deep 
punched-out  ulcer. 

Moist  Papules  {Mucous  Patches). — These  consist  in  soft  flat 
papules  covered  with  an  offensive,  grayish  secretion.  Heat 
and  moisture  favor  their  development,  so  that  their  favorite 
seats  are  around  the  arms,  the  genitalia,  the  mouth,  and  in 
women  under  the  mammae. 

Papulo-squamous  SypMloderm. — This  may  be  an  early  or 
late  manifestation,  and  is  characterized  by  a  general  erup- 
tion of  small  papules  which  are  more  or  less  scaly,  so  as  to 
resemble  psoriasis. 

Diagnosis. — The  history,  the  slight  scaling,  the  dirty-gray 
color  of  the  scales,  the  dark-red  color  of  the  lesions,  the  espe- 
cial tendency  to  involve  the  palms  and  soles  will  serve  to  dis- 
tinguish syphilis  from  psoriasis. 

Squamous  Eczema. — In  this  afiection  the  distribution,  the 
infiltration  of  the  skin,  and  the  marked  itching  will  lead  to 
a  correct  diagnosis. 

Annular  SypMloderm — In  this  form  the  lesions  consist  of 
circles  or  semi-circles  of  small  dark-red  papules. 

Pustular  SypMloderm — This  form  usually  appears  within 
the  first  year,  and  is  characterized  by  a  general  eruption  of  small 


480       DISEASES   OF   THE   SKIN   AND    ITS   APPENDAGES. 

or  large,  acuminated  or  flat  pustules  which  finally  dry  up 
and  form  yellowish-brown  crusts.  Large  lesions  leave  super- 
ficial ulcers.  The  term  rwpia  is  applied  to  large,  conical, 
stratified  crusts  which  rest  loosely  on  the  ulcerating  basis. 

Diagnosis.  Variola. — Absence  of  syphilitic  history,  the 
shot-like  feel,  the  umbilication,  the  itching,  the  high  fever,  and 
the  acute  course  will  separate  variola  from  syphilis. 

Acne. — This  is  usually  limited  to  the  face  and  shoulders ; 
there  is  no  history  of  syphilis  or  concomitant  symptoms  of 
that  affection. 

Treatment. — The  internal  treatment  consists  in  the  ad- 
ministration of  iodide  of  potassium,  mercurials,  and  tonics. 

J^L  Hydrarg.  iodic!.,  gr.  j  ; 
Potass,  iodid.,  3iv ; 
Syr.  sarsaparillse  co., 
Aquae,  aa  f|ij.— M.  *(R.  W.  Taylor.) 
Sig. — Teaspoonful  three  times  a  day  after  meals. 

Or— 

^   Hydrarg.  protiodidi,  gr.  v-x ; 

Ext.  opii,  gr.  v.— M.     (Hard away. 
Ft.  in  pil.  No.  xx. 
Sig. — One  morning  and  evening. 

Local,  Treatment. — Papular  eruptions  may  be  washed 
with  mercurial  lotions ;  mucous  patches  may  be  dusted  with 
calomel ;  ulcers  may  be  dressed  with  iodoform. 

LEPROSY. 

(Lepra,  Elephantiasis  Graecorum.) 

Definition. — A  chronic  contagious  disease,  excited  by  the 
bacillus  of  leprosy,  and  characterized  by  tubercular  formations, 
ulcerations,  atrophy,  disturbances  of  sensation,  and  an  in- 
crease or  decrease  of  pigment. 

Etiology. — The  disease  is  contagious,  but  direct  inocula- 
tion is  essential  to  its  transmission.  It  seems  to  be  more 
common  in  hot  climates.  The  exciting  cause  is  the  bacillus 
leprae,  which  closely  resembles  the  tubercle  bacillus. 

Varieties. — There  are  two  varieties  :  Tubercular  leprosy 
and  ansesthetic  leprosy ;  but  the  two  forms  are  often  associated 
in  the  same  patient. 


LEPROSY.  481 

Symptoms. — Certain  prodromes  may  precede  the  outbreak 
of  the  disease,  such  as  malaise,  headache,  chilliness,  depression 
of  spirits,  and  numbness  in  the  parts  to  be  aflPected. 

Tuherculur  Leprosy. — In  this  form  spots  of  erythema  ap- 
pear on  the  body ;  they  soon  become  pigmented  and  hyper- 
sesthetic,  and  develop  into  tubercles  varying  in  size  from  a  pea 
to  a  walnut.  The  face,  extremities,  and  genitals  are  the  parts 
most  commonly  affected,  but  occasionally  the  mucous  mem- 
branes, especially  of  the  nose  and  throat,  are  invaded.  Ulti- 
mately the  tubercles  may  break  down  and  leave  superficial 
indolent  ulcers.  In  some  cases  a  bullous  eruption  appears 
from  time  to  time.  The  hair,  eyebrows,  and  eyelashes  fall  out, 
the  eyes  become  inflamed,  the  features  distorted,  and  the  voice 
husky.  The  disease  may  last  many  years,  death  finally  result- 
ing from  exhaustion  or  some  intercurrent  disease. 

Ancesthdie  Leiyrosy. — In  this  form  the  peripheral  nerves 
are  invaded  by  the  bacillus  leprse.  The  outbreak  may  be 
preceded  by  numbness,  itching,  or  lancinating  pains.  These 
symptoms  are  followed  by  the  appearance  of  discolored  spots, 
which  are  at  first  associated  with  hypersesthesia,  but  later  more 
or  less  ansesthesia  develops.  The  skin  and  its  appendages 
atrophy,  the  bones  undergo  necrosis,  and  the  phalanges  drop 
off  one  by  one.  In  some  cases  (lepra  alba)  the  skin  is  not 
only  ansesthetic,  but  distinctly  white.  Finally,  when  the  nerves 
are  more  or  less  destroyed  paralysis  results.  The  duration  is 
many  years. 

Prognosis.  — Unfavorable.  A  cure  is  practically  impos- 
sible, though  the  progress  of  the  disease  may  be  stayed  by 
appropriate  treatment. 

Treatment.  —  Sufferers  should  be  isolated.  Tonics  are 
usually  indicated.  Chaulmoogra  oil  and  gurgun  oil,  inter- 
nally and  externally,  have  been  highly  recommended.  Exter- 
nally, chrysarobin,  ichthyol,  or  resorcin  may  be  applied  to  the 
affected  parts, 

^   Chrysarobin,  gr.  x  -  3j  ; 
^theris  et  alcoholis  ad  q.  s. 
Collodii,  f|j.— M.     (G.  H.  Fox.) 
Kub  the  chrysarobin  with  a  little  alcohol  and  ether,  and  add  the 
collodion. 

Sig. — Paint  the  affected  patch  with  a  camel' s-hair  brush. 
31 


482        DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

EPITHELIOMA. 

(Skin  Cancer.) 

Etiology. — Late  life,  heredity,  and  local  irritation  are  the 
predisposing  factors. 

Vaeieties. — Superficial,  deep-seated,  and  papillomatous. 

Superficial  Epithelioma  {Rodent  Ulcer). — This  form  usually 
begins  as  a  firm,  circumscribed,  reddish-yellow,  wax-like 
papule.  After  the  lapse  of  several  mouths  or  years  the  papule 
becomes  scaly,  and  the  removal  of  the  scales  is  followed  by  a 
slight  excoriation,  which  in  turn  becomes  covered  with  a  slight, 
reddish-brown  crust.  The  latter  tends  to  adhere,  and  its  re- 
peated removal  is  followed  by  a  raw  surface,  which  is  gradu- 
ally converted  into  an  ulcer.  The  ulcer  has  a  prominent  in- 
durated margin;  its  outline  is  irregular;  its  base  is  uneven 
and  glazed ;  and  it  exudes  a  sanious  viscid  excretion.  It  is 
not  painful ;  it  does  not  lead  to  enlargement  of  the  neighboring 
lymphatic  glands ;  nor  does  it  cause  impairment  of  the  gen- 
eral health.  It  spreads  very  slowly,  and  sometimes  becomes 
stationary  or  actually  heals.  More  frequently  the  ulceration 
continues  until  it  involves  all  the  tissues  of  the  part,  even  the 
bones.  The  ulcer  generally  appears  on  the  face,  and  in  its 
advance  it  may  destroy  the  nose,  eyes,  or  a  lar-ge  portion  of  the 
cranial  bones. 

Deep-seated  Epithelioma. — This  variety  may  begin  as  a 
deep-seated,  red,  shiny  tubercle,  or  it  may  develop  from  the 
superficial  form.  The  ulcer  which  is  ultimately  formed  is 
deep;  its  base  is  granular;  its  edges  are  everted,  iudurated, 
and  of  a  reddish-purple  color ;  it  secretes  a  blood-stained 
yellow  fluid ;  it  is  the  seat  of  lancinating  pain  ;  it  causes  en- 
largement of  the  neighboring  glands;  and  it  sooner  or  later 
indfices  the  cancerous  cachexia.  Death  may  result  from  ex- 
haustion, or  more  rarely,  from  hemorrhage  caused  by  ulcer- 
ation of  a  large  bloodvessel. 

Papillomatous  Epithelioma. — This  may  begin*  as  a  warty 
excrescence,  or  may  develop  from  one  of  the  preceding  varie- 
ties. It  is  characterized  by  an  ulcerated  surface  from  which 
springs  an  aggregation  of  large,  highly-vascular  papillae.     Be- 


AINHUM — DERMATALGIA.  483 

tween  the  papillae  there  are  often  deep-seated  fissures  from 
which  exudes  an  offensive  viscid  discharge.  The  general 
health  is  impaired  and  the  neighboring  glands  are  enlarged. 

Diagnosis.  Lupus  Vulgaris. — Lupus  begins  in  the  young ; 
the  original  papule  is  soft ;  there  is  often  more  than  one  centre 
of  ulceration ;  the  margins  of  the  ulcer  are  not  hard  and 
everted  ;  the  progress  is  extremely  slow  ;  the  discharge  from 
the  ulcer  is  very  scant,  and  the  bones  are  never  involved. 

Syphilis. — The  history,  the  associated  evidences  of  syphilis, 
the  rapid  progress  of  the  ulceration,  the  abundant  discharge, 
the  absence  of  pain,  and  the  effect  of  treatment  will  suggest 
the  diagnosis. 

Prognosis. — Guarded.  A  thorough  removal  in  the  begin- 
ning of  the  disease  is  often  followed,  by  a  permanent  cure. 
When  the  process  is  advanced  the  growth  usually  returns. 

Treatment. — Epitheliomatous  growths  may  be  removed 
by  the  use  of  caustics,  the  cautery,  the  curette,  or  by  ex- 
cision. The  last  is  preferable  when  the  growth  is  small  and 
circumscribed. 

AINHUM. 

Ainhum  is  a  rare  affection,  occurring  chiefly  in  the  colored 
race,  and  characterized  by  the  appearance  of  a  groove  or  fur- 
row at  the  base  of  one  or  more  of  the  toes.  The  groove  deep- 
ens, the  affected  member  becomes  swollen,  and  finally  drops 
off  at  the  point  of  strangulation. 

DERMATALGIA. 

Dermatalgia,  or  neuralgia  of  the  skin,  is  a  rare  affection, 
and  is  characterized  by  paroxysms  of  sharp,  lancinating  pain 
in  the  skin,  which  arise  without  any  change  in  the  local  ap- 
pearance. It  is  most  frequently  observed  in  women  of  a 
neuropathic  tendency,  and  may  arise  from  any  of  the  causes 
which  induce  neuralgia  elsewhere. 

Treatment. — ^The  cause  must  be  sought  for  and,  if  pos- 
sible, removed.  Tonics  like  iron,  arsenic,  quinine,  and  phos- 
phorus are  often  indicated.  Locally,  massage  and  electricity 
may  prove  useful. 


484       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 


PRURITUS. 

Definition. — Pruritus  is  a  functional  aflfection,  character- 
ized by  itching  which  is  unassociated  with  any  objective  phe- 
nomena. 

Etiology — Pruritus  ruay  arise  without  obvious  cause,  as 
the  Pruritus  senilis  observed  in  the  old,  and  the  pruritus 
hiemalis  which  develops  on  the  approach  of  cold  weather  and 
disappears  when  the  weather  becomes  warm. 

Symptoinatie  Pruritus. — Pruritus  may  be  a  symptom  of 
many  conditions,  notably  diabetes,  gout,  lithsemia,  hysteria, 
neurasthenia,  and  Bright's  disease. 

Symptoms. — There  is  only  one  symptom  and  that  is  itching  ; 
but  as  a  result  of  scratching,  the  part  may  become  hypersemic, 
thickened,  or  the  seat  of  eczema. 

Diagnosis. — Pruritus  must  be  distinguished  from  the  itch- 
ing induced  by  pediculosis,  or  some  local  disease,  like  eczema. 

Prognosis. — This  will  depend  on  the  cause.  When  the 
primary  disease  is  curable  the  prognosis  for  permanent  relief 
is  favorable.  In  other  cases  temporary  relief  only  is  to  be  ex- 
pected. 

Treatment. — Search  should  be  made  for  the  exciting 
cause,  which  should  be  removed,  if  possible.  In  all  cases  the 
urine  must  be  examined  for  sugar,  since  diabetes  is  one  of  the 
most  frequent  causes  of  pruritus.  Among  the  internal  reme- 
dies recommended  for  pruritus  may  be  mentioned  nux  vomica, 
belladonna,  and  pilocarpine.  The  best  local  remedies  are  car- 
bolic acid,  vinegar,  thymol,  chloral-camphor,  boric  acid, 
hydrocyanic  acid,  hot  water,  and  menthol. 

^   Acid,  hydrocyan.  dil.,  f^ij  ; 
Sodii  borat.,  3j  ; 
Aq.  rosee,  f  ^viij. — M.     (Fox.) 
Sig. — Use  locally. 

^  Menthol,  giss ; 

Alcoholis,  f^iv. — M. 
Sig. — Use  locally. 

^  Acid,  carbolic,  fsi-f^ij  ; 

Aquse  et  alcohol.,  aa  q.  s.  ad  Oj. — M. 
Sig. — Apply  locally  as  often  as  necessary. 


TENEA  TRICOPHYTINA.  485 

TINEA  TRICOPHYTEVA. 

(Ringworm.) 

Definition. — A  contagious  disease  excited  by  a  vegetable 
parasite — the  tricophyton. 

Varieties. — On  the  scalp  it  is  termed  Tinea  tonsurans  ;  on 
the  body,  Ti7iea  circinata ;  on  the  bearded  region,  Tinea 
sycosis. 

Tinea  Tonsurans. 

This  form  is  observed  almost  exclusively  on  the  scalp  of 
children.  It  is  characterized  by  one  or  more  rounded,  scaly, 
elevated,  grayish-colored  patches  through  which  project  dry, 
brittle,  lustreless,  broken-off  hairs. 

Diagnosis.  Seborrhoea. —  The  patches  are  not  circum- 
scribed ;  the  scales  are  greasy ;  the  hair  is  not  involved  ;  and 
the  microscope  reveals  no  parasite. 

Eczema. — The  patches  are  not  circumscribed  ;  the  hair  is 
not  involved ;  there  is  more  inflammation ;  there  is  marked 
itching ;  and  the  microscope  reveals  no  parasite. 

Alopecia  Areata. — Baldness  is  complete  ;  there  are  no  scales; 
and  the  base  is  smooth  and  shiny. 

Prognosis. — Favorable. 

Treatment. — Tonics  are  often  indicated.  The  parts 
should  be  thoroughly  washed  with  soap  and  water,  and  the 
afi'ected  hairs  removed.  The  following  parasiticides  may  be 
employed  in  ointment  or  lotion  ;  mercury,  sulphur,  chrysarobin, 
or  sulphurous  acid. 

^  Acid,  sulphurosi,  ff  j  ; 
Aquse,  f|iv. — M. 
Sig. — Apply  several  four  or  five  times  daily. 

Or— 

R     Acidi  salicylici,  gr.  xxx; 
Sulphuris  prtecip.,  3j  ; 
Vaselini,  §j. — M. 
Sig. — Rub  into  affected  area  once  or  twice  daily.         (Hardaway.) 


486       DISEASES   OP  THE  SKIN  AND   ITS   APPENDAGES. 

Tinea  Circinata. 

(RingTvonn  of  the  Body.) 

This  appears  as  one  or  more  rounded,  red,  slightly-elevated 
scaly  patches,  which  on  close  examination  reveal  minute 
vesicles  or  papules.  As  the  disease  advances  new  patches 
spring  from  the  periphery  while  the  central  portion  clears  up. 
There  is  often  considerable  itching. 

Diagnosis.  Psoriasis. — The  marked  scaling ;  the  absence 
of  itching ;  the  tendency  to  involve  the  extensor  surfaces,  es- 
pecially the  knees  and  elbows ;  and  the  absence  of  the  tri- 
cophyton  will  separate  psoriasis  from  ringworm. 

Eczema. — The  patches  are  ill  defined  ;  there  is  more  itching; 
there  is  more  infiltration  of  the  skin  ;  and  there  is  no  trico- 
phyton. 

Prognosis. — Favorable. 

Treatment. — Tonics  are  frequently  indicated  ;  mercury, 
sulphur,  sulphurous  acid,  and  hyposulphite  of  sodium  are 
among  the  best  parasiticides. 

^   Sodii  hyposulphit.,3ij  ; 

Aquse,  Y^ij.— M.     (Duheing.  ) 
Sig. — Apply  locally. 

Or— 

^   Hydrarg.  ammoniat.,  gr.  xxx  ; 
Adipis,  ^j. — M. 
Sig. — Apply  locally. 

Tinea  Sycosis. 

(Barber's  Itch,  Sycosis  Parasitica.) 

This  begins  as  a  red  scaly  patch  involving  the  bearded 
region.  Soon  purplish  tubercles  and  pustules  form  around 
the  opening  of  the  hair-follicles,  and  the  hairs  become  lustre- 
less, brittle,  and  loose.      There  is  often  considerable  itching. 

Diagnosis.  Simple  Sycosis. — In  this  the  inflammation  is 
superficial ;  the  hairs  are  not  involved ;  and  the  tricophyton 
is  absent. 


TINEA   VERSICOLOR.  487 

Eezema. — The  tubercles,  the  involvement  of  the  hairs,  and 
the  presence  of  the  tricophyton  will  separate  it  from  eczema. 

Prognosis. — Favorable  ;  unless  treated  actively,  however, 
there  may  be  a  permanent  loss  of  hair. 

Treatment. — The  affected  hairs  should  be  removed,  and 
one  of  the  following  parasiticides  employed  in  lotion  or  oint- 
ment :  Mercury,  sulphur,  or  hyposulphite  of  sodium. 

^   Sodii  hyposulphit.,  ^iij  ; 
Aquee,  f!§iij. — M. 
Sig. — Apply  locally. 
Or— 

^   Sulphur,  sublimat.,  ^ij  ; 
Yaselini,  ^ij. 
Sig. — Apply  locally. 

ti]vt:a  versicolor. 

(Pityriasis  Versicolor.) 

Definition. — A  chronic  affection  excited  by  a  vegetable 
parasite,  the  microsporon  furfur,  and  characterized  by  salmon- 
colored  scaly  patches  which  usually  appear  about  the  chest. 

Etiology. — It  is  a  disease  of  adult  life,  and  is  more  fre- 
quently observed  in  the  debilitated  and  uncleanly. 

Symptoms. — It  appears  usually  on  the  front  of  the  chest  as 
small  round  spots  of  a  pale-yellow  or  fawn  color,  which  slowly 
enlarge,  fuse,  and  form  slightly-elevated  scaly  patches.  Sub- 
jective symptoms  are  generally  absent. 

Diagnosis. — Chloasma  somewhat  resembles  tinea  versi- 
color ;  but  the  former  is  not  often  observed  on  the  trunk,  is 
not  scaly,  and  is  not  associated  with  a  parasite. 

Prognosis. — Favorable. 

Treatment. — The  parts  should  be  frequently  washed  with 
soap  and  water,  after  which  one  of  the  following  parasiticides 
may  be  applied  :  Corrosive  sublimate  (gr.  ij  to  an  ounce  of 
water),  sulphurous  acid,  or  hyposulphite  of  sodium  : — 

^   Sodii  hyposulphitis,  ^v  ; 
G-lycerini,    f^iij  ; 
Aquse,  q.  s.  ad  f^v. — M. 
Sig. — Apply  locally. 


488        DISEASES    OF   THE   SKIN    AND   ITS   APPENDAGES. 

Or— 

1^   Hydrarg.  chlor.  corros. ,  9 j  ; 
Alcoholis,  f^iv ; 
Saponis  viridis,  31] ; 

01.  lavandulffi,  f^j. — M.     (Van  Harlingen.) 
Sig. — To  be  rubbed  ia  well  uigbt  and  morning. 

TINEA  FAVOSA. 

(Favus.) 

Definition. — A  contagious  affection  of  the  scalp  excited 
by  the  aehonon  Schonleinii,  and  characterized  by  yellowish^ 
cup-shaped  crusts. 

Etiology. — It  is  observed  especially  in  poor,  ill-nourished 
children. 

Symptoms. — The  disease  is  characterized  by  one  or  more 
rounded,  yellow,  cup-shaped  crusts,  through  which  project 
dry,  brittle,  lustreless  hairs.  The  underlying  tissue  is  more 
or  less  atrophied  and  scarred.  It  is  associated  with  some  itch- 
ing and  a  peculiar  musty  odor. 

Diagnosis. — The  yellow,  cup-shaped  crusts,  the  odor,  and 
the  atrophy  of  the  skin  will  separate  it  from  ringworm. 

Prognosis. — Favorable  When  not  treated  early  it  may 
be  followed  by  permanent  baldness. 

Treatment. — The  crusts  should  be  removed  by  oil,  or 
soap  and  water.  The  affected  hairs  should  also  be  removed. 
The  following  parasiticides  are  efficient :  Mercury,  sulphur, 
chrysarobin,  and  hyposulphite  of  sodium. 

SCABIES. 

(Itch.) 

Definition. — Scabies  is  a  contagious  disease  excited  by  an 
animal  parasite — the  Acarus  Soabiei — and  manifested  by  pap- 
ules, vesicles,  pustules,  burrows,  and  intense  itching. 

Etiology. — The  disease  is  always  acquired  through  inti- 
mate intercourse  with  patients  already  affected. 

Symptoms. — The  disease  manifests  itself  by  intense  itching, 
which  is  associated  with  an  eruption  of  small  papules,  vesicles, 


PEDICULOSIS.  489 

and  pustules.  Among  these  lesions  may  be  found  cuniculi,  or 
burrows ;  these  are  discolored,  dotted,  slightly  elevated  lines 
ranging  from  a  line  to  half  an  inch  in  length,  and  produced 
by  the  penetration  of  the  female  acarus  aud  the  deposition 
of  her  eggs  along  the  passage.  The  parts  most  commonly 
affected  are  the  hands  between  the  fingers,  the  wrists,  the 
axillse,  the  genitalia,  beneath  the  mammee,  and  the  inner 
aspects  of  the  thighs.     The  face  and  scalp  are  never  involved. 

Diagnosis. — The  recognition  of  scabies  rests  on  the  history, 
the  itching,  the  presence  of  burrows,  the  multiformity  of  the 
lesions,  and  their  peculiar  distribution. 

Prognosis. — Favorable. 

Treatment. — The  following  remedies  are  efficient :  Sul- 
phur, styrax,  and  naphthol. 

]^   Sulphur,  sublimat.,  gj  ; 
Balsam.  Pei'uvian.,  ges ; 
Adipis,  5j.— M.     (Duhring.) 
Sig. — Eub  in  thoroughly  twice  daily. 


Or- 


Or— 


^.   Naphthol.,  gr.  Isxx  ; 
Saponis  viridis,  §ss ; 
Cretse  alb.  pulv. ,  gr.  1 ; 
Adipis,  §j. — M.    '(Kaposi.) 


^   Storacis,  f|j  ; 

Spt.  vin.  rect.,  f^ij. — M. 
Et  adde — 

01.  olivse,  fgj.     (McCall  Anderson.) 
Sig. — Eub  the  parts  thoroughly  ;  repeat  in  twenty-four  hours. 

PEDICULOSIS. 

(Phtheiriasis.) 

Pediculosis  Capitis — This  form  resuhs  from  the  pediculus 
capitis,  or  head-louse,  a  gray  insect  from  one  to  two  milli- 
metres in  length.  The  condition  is  recognized  by  itching  of 
the  scalp  and  the  discovery  of  the  lice  or  their  white  ova,  or 
nits.  Eczematous  lesions  resulting  from  scratching  are  often 
observed. 


490       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

Pediculosis  Corporis. — This  form  results  from  the  pedicukis 
corporis,  pediculus  vestimenti,  or  body-louse,  a  somewhat 
larger  insect  than  the  head-louse.  The  condition  is  recog- 
nized by  intense  itching  on  the  covered  parts  of  the  body, 
scratch-marks,  petechise  caused  by  the  bite  of  the  insect,  and 
the  discovery  of  the  lice  on  the  garments. 

Pediculosis  Pubis, — This  form  results  from  the  pediculus 
pubis,  or  crab-louse,  a  minute,  gray,  translucent  insect.  It  is 
found  on  parts  covered  with  short  hair,  as  the  pubes,  axillae, 
eyebrows,  etc. 

Treatment. — In  pediculosis  capitis  the  head  may  be  thor- 
oughly washed  with  coal-oil,  dilute  carbolic  acid  (3j  to  Oj),  or 
tincture  of  cocculus  indicus. 

In  pediculosis  corporis  the  parts  should  be  thoroughly  washed 
and  the  clothes  subjected  to  a  high  temperature.  The  body  may 
be  bathed  in  a  weak  solution  of  corrosive  sublimate. 

In  pediculosis  pubis  an  ointment  of  mercury  is  very  efficient. 


APPENDIX. 


EXAMINATION  OF  THE  BLOOD. 

A  CLINICAL  study  of  the  blood  has  for  its  object  the  deter- 
mination of  the  percentage  of  hsemoglobiu,  the  specific  grav- 
ity, the  alkalinity,  the  number,  form,  and  relative  proportion 
of  the  various  corpuscles,  and  the  detection  of  free  pigment, 
bacteria,  and  animal  parasites. 

Estimation  of  HaBmoglobin. — The  percentage  of  haemo- 
globin may  be  determined  by  either  Fleischl's  or  Gowers' 
apparatus,  although  the  former  is  preferable. 

Gowers^  hcemoglobinometer  consists  of  (1)  a  small  sealed  tube 
containing  coloring  matter  representing  the  color  of  normal 
blood  diluted  with  100  parts  of  water ;  (2)  an  empty  tube  of 
the  same  size,  graduated  up  to  120  per  cent. ;  (3)  a  small  bot- 
tle with  a  pipette  stopper,  for  distilled  water ;  (4)  a  capillary 
pipette  for  measuring  20  c.mm.  of  blood ;  and  (5)  a  small 
lancet.  To  obtain  a  specimen  of  blood  the  tip  of  the  finger  or 
the  lobe  of  the  ear,  after  being  thoroughly  cleansed,  is  deeply 
pricked  with  the  lancet,  so  that  the  blood  flows  freely  without 
squeezing ;  20  c.mm.  of  blood  are  then  drawn  into  the  capillary 
pipette,  and  are  immediately  blown  into  the  graduated  tube, 
in  which  have  been  previously  placed  a  few  drops  of  distilled 
water  to  prevent  coagulation.  After  shaking  the  mixture  to 
secure  diffusion  of  the  blood,  more  distilled  water  is  cautiously 
added,  with  occasional  shaking,  until  the  tint  in  the  sealed 
tube  is  reached.  The  height  of  the  column  of  the  fluid  in  the 
graduated  tube  will  indicate  the  percentage  of  hsemoglobiu, 

FleisGhVs  instrument  consists  of  a  metal  stand  with  a  circu- 
lar aperture  in  the  centre,  under  which  is  placed  a  reflector 
made  of  plaster-of-Paris.  The  aperture  is  fitted  with  a  small 
cell  having  a  glass  bottom,  and  divided  into  two  equa,l  com- 
partments,    A  graduated  wedge  of  colored  glass  is  employed 

491 


492  APPENDIX. 

as  a  standard,  the  100  on  the  scale  being  intended  to  repre- 
sent the  percentage  of  haemoglobin  in  normal  blood.  This 
wedge  of  glass  is  so  arranged  that  when  moved  under  the 
stand,  one  compartment  of  the  cell  will  receive  white  light 
from  the  reflector,  and  the  other,  red  light  from  the  tinted  glass. 
A  small,  capillary  tube  is  held  over  a  drop  of  blood  until  filled, 
and  is  then  washed  in  one  of  the  compartments  of  the  cell,  in 
which  has  been  previously  placed  some  distilled  water.  Both 
compartments  are  then  equally  filled  with  water,  and  the 
wedge  of  glass  is  moved  by  means  of  a  thumb-screw  until 
the  tints  in  the  two  chambers  are  exactly  the  same,  when  the 
percentage  of  haemoglobin  may  be  read  off. 

In  the  examination  it  is  necessary  to  use  artificial  light. 
The  100  mark  on  the  scale,  which  is  intended  to  represent  the 
percentage  of  haemoglobin  in  normal  blood,  is  too  high  for  the 
average  person,  85  or  90  per  cent,  rarely  being  exceeded. 

The  Specific  Gravity  of  the  Blood. — The  specific 
gravity  of  the  blood  in  health  varies  from  1050  to  1070.  In 
grave  anaemia  it  is  often  considerably  diminished.  Hammer- 
schlag's  method  consists  in  expelling  a  drop  of  blood  into  a 
mixture  of  chloroform  and  benzol,  one  or  the  other  of  these 
substances  being  subsequently  added  until  the  drop  neither 
rises  nor  falls.  The  specific  gravity  of  the  mixture  may  then 
be  ascertained  in  the  usual  way.  Lloyd  Jones  employs  mix- 
tures of  glycerine  and  water  of  different  densities,  and  notes 
the  specific  gravity  of  the  mixture  in  which  the  blood-drop 
remains  stationary. 

Alkalinity  of  the  Blood. — The  alkalinity  of  the  blood 
may  be  determined  by  titrating  with  a  standard  solution  of 
acetic  acid  until  a  change  of  color  is  produced  when  a  drop  is 
placed  on  a  plaster-of-Paris  plate  impregnated  with  neutral 
litmus. 

Enumeration  of  Corpuscles. — The  best  instruments  for 
estimating  the  number  of  corpuscles  are  the  hcemocytometer 
of  Thoma-Zeiss,  and  the  hcematokrit  of  Blix-Hedin.  The 
former  consists  of  a  glass  slide  in  the  centre  of  which  is  a  cell 
jlg-  mm.  in  depth.  The  floor  of  the  cell  is  divided  into 
squares,  the  sides  of  which  are  -^  mm.  Twenty-five  small 
squares  constitute  a  large  square  which  is  indicated  by  heavy 
lines.     The  blood  is  mixed  in  a  melangeur — that  is,  a  capil- 


EXAMINATION   OF   THE   BLOOD.  493 

lary  tube  one  extremity  of  which  is  blown  into  a  bulb  having 
a  capacity  of  100  c.mm.  The  m§]angeur  is  marked  at  0.5,  1 
c.mm.  and  101  c.mm.  A  drop  of  blood  issuing  from  a  prick 
of  the  finger  or  lobe  of  the  ear  is  drawn  cautiously  into  the 
tube  to  the  1  c.mm.  mark.  The  point  is  quickly  wiped  and 
immersed  in  the  diluting  iiuid  (2J  per  cent,  solution  of  potas-" 
slum  bichromate)  which  is  drawn  up  to  the  101  c.mm.  mark. 
The  instrument  is  now  shaken  to  secure  diffusion  of  the  blood. 
The  diluting  fluid  remaining  in  the  stem  of  the  melaugeur  is 
now  blown  out,  and  a  drop  of  the  mixture  placed  in  the 
blood-counting  cell.  The  drop  in  the  cell  should  be  free  from 
bubbles,  and  the  cover-glass  so  adjusted  that  Newton's  rings 
appear  at  the  margin  of  the  drop.  Before  counting,  a  few 
minutes  should  be  allowed  for  the  corpuscles  to  settle  to  the 
bottom  of  the  cell.  The  number  of  corpuscles  is  then 
counted  in  sixteen  large  squares  (400  small  squares),  the  aver- 
age number  in  each  small  square  being  determined  by  divid- 
ing the  whole  sum  by  400.  This  number  is  then  multiplied 
by  400,000,-100  for  the  dilution,  and  20  X  20  X  10  for  the 
cube  of  the  cell. 

After  using,  the  m^langeur  should  be  carefully  washed  in 
water,  alcohol,  and  ether. 

The  number  of  red  blood-corpuscles  per  cubic  millimeter 
may  be  estimated  even  more  conveniently,  and  quite  as  accu- 
rately, by  means  of  the  hsematokrit.  This  instrument  con- 
sists of  a  centrifuge,  to  which  is  attached  a  metallic  frame, 
carrying  two  graduated  capillary  glass  tubes,  in  which  is 
placed  the  blood  freshly  drawn.  A  speed  of  10,000  revolu- 
tions per  minute  is  easily  secured,  and  under  this  centrifugal 
force  the  heavy  red  blood-corpuscles  are  soon  driven  to  the 
distal  end  of  the  tube,  when  the  number  per  cubic  millimeter 
can  be  determined  by  means  of  the  scale  marked  on  the  glass. 

The  Study  of  the  White  Blood-corpuscles. — In  nor- 
mal blood,  five  varieties  of  white  blood-corpuscles  (Fig.  22) 
may  be  observed : 

1.  Lymphocytes,  or  small  mononuclear  forms,  about  the  size 
of  red  blood-corpuscles,  with  large  deeply  staining  nuclei,  and 
a  narrow  margin  of  non-granular  protoplasm.  They  have 
their  origin  in  the  lymph-glands,  and  constitute  about  20  to  30 
per  cent,  of  all  the  leucocytes. 


494 


APPENDIX. 


2.  Large  mononuclear  cells,  three  or  four  times  the  size 
of  the  red  blood-corpuscles,  with  oval  nuclei,  surrounded  by 
non-granular  protoplasm. 

3.  Transitional  forms,  differing  from  the  large  mononuclear 
cells   only  in   having   nuclei  with    indentations.     The   large 


Fig.  22. 


a,  Lymphocyte ;  6,  large  mononuclear  cell ;  c,  transitional  form ;  d,  polynuclear  form ; 
e,  eosinophilic  leucocyte. 

mononuclear  forms  constitute  from   6  to  8  per  cent,  of  the 
whole  number  of  leucocytes. 

4.  Polynuclear  Forms,  or  Leucocytes  with  Polymorphous 
Nuclei. — These  are  somewhat  smaller  than  the  large  mononu- 
clear forms,  and  contain  deeply-staining  nuclei  which  are  very 
variable  in  shape.  The  protoplasm  contains  abundant  neutro- 
philic granules  (neutrophiles) — that  is,  granules  whicii  have  an 
affinity  for  a  combination  of  acid  and  basic  stains.  The  poly- 
nuclear forms,  or  neutroj^hiles,  are  apparently  derived  from  the 
spleen  and  bone-marrow,  and  constitute  from  70  to  80_  per 
cent,  of  all  forms. 

5.  Eosinophiles. — These  resemble  in  general  appearance  the 
polynuclear  forms,  but  the  granules  are  larger,  more  highly 
refractive,  and  have  a  special  affinity  for  acid  stains,  particu- 
larly eosin.  They  have  their  origin  in  the  bone-marrow,  and 
constitute  from  2  to  4  per  cent,  of  all  forms. 


EXAMINATION   OF   THE   BLOOD.  495 

In  addition  to  the  normal  elements  above  mentioned,  cer- 
tain other  forms  may  be  observed  in  the  blood  of  disease. 
Thus  in  leucaemia  very  large  mononuclear  forms  [myelocytes) 
are  often  met  with,  the  protoplasm  of  which  is  studded  with 
neutrophilic  granules.  In  the  same  disease,  the  blood  occa- 
sionally contains  cells  resembling  those  normally  found  in  - 
connective  tissue  (Mastzellen).  They  are  peculiar  in  having 
granules  which  have  an  affinity  only  for  basic  stains. 

With  the  aid  of  a  one-twelfth  inch  oil-immersion  lens,  large 
and  small  leucocytes  can  be  readily  distinguished  in  prepara- 
tions of  fresh  blood,  but  to  study  satisfactorily  the  various 
forms  it  is  necessary  to  dry  and  then  stain  the  specimen. 

The  Drying  and  Staining  of  Blood. — A  small  drop 
of  blood,  secured  by  pricking  the  finger,  is  spread  into  a  film 
by  being  pressed  between  two  perfectly  clean  cover-glasses, 
which  are  then  drawn  apart  and  exposed  to  the  air  until  dry. 
The  cover-glasses  should  be  handled  with  forceps,  since  the 
moisture  of  the  fingers  distorts  the  corpuscles.  The  prepara- 
tion is  first  "  fixed  "  by  heating  on  a  copper  bar  for  several 
hours  at  a  temperature  of  110°  to  120°  C.,  or  by  immersing 
for  from  fifteen  minutes  to  half  an  hour  in  a  mixture  of  equal 
parts  of  absolute  alcohol  and  ether.  A  convenient  method  of 
staining  is  the  one  suggested  by  Stengel.  The  fixed  prepara- 
tion is  immersed  for  a  couple  of  minutes  in  a  1  per  cent,  solu- 
tion of  eosin  in  60  per  cent,  alcohol,  to  which  has  been  added 
an  equal  quantity  of  water  at  the  time  of  staining.  The 
cover-glass  is  then  washed  in  water  and  counter-stained  in 
Delafield's  hsematoxylin  for  a  minute,  and  finally  washed, 
dried,  and  mounted.  The  eosinophile  granules  are  dark  red, 
the  red  corpuscles  lighter  red,  and  the  nuclei  of  the  white 
blood-corpuscles  almost  black.  Thayer  recommends  the  fol- 
lowing solution : 

Solution : 

Saturated  aqueous  solution  of  acid  fuchsin    ....  2      parts. 

Water 3         " 

Saturated  aqueous  solution  of  orange-green    ....  6.25     " 
Saturated  aqueous  solution  of  methyl-green  ....  6  " 

To  which  is  added  drop  by  drop  while  the  solution  is  shaken : 

Water      15  parts. 

Alcohol 10      " 

Glycerin 5      " 


496  APPENDIX. 

The  fixed  specimen  is  stained  in  this  solution  for  from  three 
to  four  minutes,  washed  in  water,  dried  in  the' air,  and  mounted 
in  balsam.  The  nuclei  of  white  blood-corpuscles  appea,r  green, 
the  eosinophile  granules  dark  red,  the  neutrophile  granules 
violet,  the  red  blood-corpuscles  orange,  and  the  nuclei  of  any 
existing  nucleated  red  blood-corpuscles  dark  green. 


EXAMINATION     OF     THE     GASTRIC 
CONTENTS. 

The  test-meal  recommended  by  Ewald  consists  of  an  ordi- 
nary dry  roll  and  two-thirds  of  a  pint  of  water  or  weak  tea, 
without  milk  or  sugar.  One  hour  after  the  ingestion  of  this 
meal  about  40  c.cm.  of  fluid  should  be  obtained  from  the 
stomach  by  expression.  When,  however,  lactic  acid  as  a 
pathological  element  is  sought  for,  it  is  necessary  to  prescribe 
a  meal  which  contains  no  preformed  lactic  acid.  The  one  rec- 
ommended by  Boas  is  now  commonly  employed  ;  it  is  a  flour- 
soup  consisting  of  a  tablespoonful  of  oatmeal  to  a  litre  of  water, 
and  flavored  with  a  little  salt.  Before  administering  this  meal 
the  stomach  should  be  thoroughly  cleansed  of  any  existing 
residue  that  might  mar  the  result  of  the  test. 

Test  for  Free  Acids. — Filter-paper  soaked  in  a  solution 
of  Congo-red,  and  dried,  turns  blue  in  the  presence  of  free 
acids.  A  saturated  alcoholic  solution  of  tropseolin  00  turns 
from  a  brownish  yellow  to  a  dark  brown  when  brought  in  con- 
tact with  fluids  containing  free  acids. 

Qualitative  Tests  for  HCL— Giinzsburg's  phloroglucin- 

vanillin  test  will  react  with  1  part  of  HCl  in  15,000  parts  of 
water.  The  solution  consists  of  2  parts  of  phlorogluciu,  1  part 
of  vanillin,  and  30  parts  of  absolute  alcohol.  When  a  few 
drops  of  this  solution  are  heated  with  an  equal  quantity  of  the 
filtrate  contained  in  a  porcelain  dish,  a  beautiful  red  color  ap- 
pears at  the  margin  of  the  fluid.  Boas  states  that  the  test  is 
still  more  delicate  when  100  parts  of  80  per  cent,  alcohol  are 
substituted  for  the  30  parts  of  absolute  alcohol. 

Boas'  resorein-sugar  test  gives  a  similar  reaction.     The  re- 


EXAMINATION   OF   THE    GASTRIC   CONTENTS.  497 

agent  consists  of  5  parts  of  resorcin,  3  parts  of  sugar,  and  100 
parts  of  diluted  alcohol. 

Total  Acidity. — This  is  determined  by  allowing  a  deci- 
normal  alkali  solution  (water  10  c.cm.,  hydrate  of  potassium 
56  milligrammes)  to  flow  from  a  burette,  drop  by  drop,  into  a 
beaker  containing  10  c.cm.  of  filtered  gastric  juice,  to  which  have 
been  added  as  an  indicator  two  drops  of  an  alcholic  solution  of 
phenol-phthalein.  The  test  is  completed  when  the  red  color 
produced  no  longer  disappears  on  shaking  the  solution.  Ten 
c.cm.  of  normal  gastric  juice  usually  require  from  4  to  6.5 
c.cm.  of  the  standard  alkali  solution. 

Since  1  c.cm.  of  the  alkali  solution  is  equivalent  to  0.00364 
gramme  of  HCl,  it  follows  that  the  percentage  of  the  latter  in 
a  given  specimen  will  equal  the  number  of  c.cm.  of  the  alkali 
solution  required  multiplied  by  10,  and  again  by  0.00364. 

Test  for  Lactic  Acid. — Dilute  solutions  of  neutral  ferric 
chloride  turn  canary  yellow  in  the  presence  of  lactic  acid. 
TJffelmann^s  reagent  is  made  by  mixing  one  or  two  drops  of 
pure  carbolic  acid  with  a  few  drops  of  dilute  solution  of  neutral 
ferric  chloride,  and  adding  sufficient  water  to  turn  the  solution 
a  beautiful  amethyst-blue  color.  Unfortunately  other  sub- 
stances, such  as  sugar,  alcohol,  acid  phosphates,  and  tartaric 
acid,  give  a  somewhat  similar  reaction.  The  test  is  made  more 
reliable  by  exhausting  a  portion  of  the  gastric  filtrate  with 
pure  ether,  evaporating  the  ethereal  extract,  and  finally  testing 
an  aqueous  solution  of  the  residue. 

Boas'  test,  though  somewhat  complicated,  is  far  more  reliable. 
The  gastric  contents  secured  after  the  ingestion  of  the  flour- 
soup  test-meal  are  filtered,  and  if  the  presence  of  free  acids  be 
indicated  by  Congo-red,  an  excess  of  barium  carbonate  is  added. 
The  filtrate  is  then  evaporated  to  the  consistence  of  syrup,  and 
the  CO2  is  driven  ofi"  by  boiling  with  a  few  drops  of  phos- 
phoric acid.  The  mixture  is  then  thoroughly  exhausted  with 
ether  that  is  absolutely  free  from  alcohol,  the  ethereal  extract 
evaporated,  and  the  residue  dissolved  in  45  c.cm.  of  water. 
The  aqueous  solution  is  poured  into  a  flask,  and  treated  with 
5  c.cm.  of  sulphuric  acid  and  a  small  quantity  of  manganese 
dioxide.  A  bent-glass  tube  is  made  to  connect  the  flask  with 
a  mixture  of  equal  parts  of  a  deci-normal  iodine  solution  and 
a  deci-normal  sodium  hydrate  solution.     On  heating  the  con- 

32 


498  APPENDIX. 

tents  of  the  flask  to  the  boiliug-point,  the  alkaline  iodine  solu- 
tion becomes  smoky  and  the  odor  of  iodoform  is  detected  when 
lactic  acid  is  present. 

Test  for  Acetic  Acid. — This  acid  may  be  detected  by  its 
odor.  The  production  of  a  blood-red  color  on  the  addition  of 
a  neutral  solution  of  ferric  chloride  to  an  aqueous  solution  of 
the  ethereal  extract  which  has  been  neutralized  with  sodium 
carbonate  also  indicates  the  presence  of  acetic  acid. 

Test  for  Butyric  Acid. — This  acid  strikes  a  brownish- 
yellow  color  with  Ufielmann's  reagent.  Its  odor  is  also  cha- 
racteristic. 

Test  for  Peptones  and  Propeptones. — These  substances 
are  the  products  of  albumin  digestion,  and  may  be  detected  by 
the  biuret  test.  When  potassium  hydrate  and  dilute  copper  sul- 
phate are  added  to  a  solution  of  peptone  a  deep  purple-red  color 
is  struck.  With  propeptone  the  reaction  is  the  same  ;  with  al- 
bumin, however,  the  color  is  bluish-violet.  The  amount  of 
peptone  may  be  roughly  estimated  by  first  precipitating  the 
albumin  and  propeptone  by  saturating  the  filtrate  with  crys- 
tals of  ammonium  sulphate,  and  then  noting  the  intensity  of 
the  color  reaction  with  the  biuret  test. 

Test  for  Rennet. — This  may  detected  by  adding  to  10 
c.cm.  of  boiled  milk  having  a  neutral  reaction  an  equal  quan- 
tity of  neutralized  filtrate.  When  the  mixture  is  treated  in  a 
water  bath  to  a  temperature  of  30°  to  40°  C,  a  cake  of  casein 
forms  in  from  15  to  20  minutes. 

Test  for  Pepsin. — Ewald  recommends  the  following 
method  of  determining  in  a  given  specimen  whether  the  pep- 
sin or  hydrochloric  acid  is  present  in  too  great  or  too  small 
amount :  An  equal  quantity  of  the  filtrate  is  placed  in  four 
small  test-tubes,  and  a  disk  of  coagulated  white  of  egg  put 
into  each.  To  the  first  nothing  else  is  added ;  to  the  second 
2  drops  of  hydrochloric  acid  is  added  for  each  6  c.cm.  of  stom- 
ach contents;  to  the  third  from  0.2  to  0.5  gramme  of  pepsin 
is  added ;  and  to  the  fourth  both  the  hydrochloric  acid  and 
pepsin  are  added.  The  test-tubes  are  then  placed  in  an  incu- 
bator at  about  100°  F.  The  rapidity  with  which  the  albu- 
min is  liquefied  in  the  different  tubes  w^ell  indicated  whether 
digestion  would  have  occurred  without  having  added  anything, 
or  whether  acid  or  pepsin  or  both  were  necessary. 


EXAMINATION    OF   THE    GASTEIC    CONTENTS.  499 

Test  for  Carbohydrates. — In  health  the  digestion  of 
starch  is  practically  completed  within  an  hour ;  after  that  time 
dextrins,  maltose,  and  dextrose  should  be  found  instead  of 
starch.  If  the  last  substance  remain  undigested  it  may  be 
detected  by  the  blue  color  which  it  strikes  with  Lugol's  solu- 
tion. With  erythrodextrin  the  iodine  solution  gives  a  purple 
color,  but  with  maltose  and  dextrose  there  is  no  reaction. 

The  Absorptive  Power  of  the  Stomach. — This  is  de- 
termined by  the  time  required  for  free  iodine  to  appear  in  the 
saliva  after  the  ingestion  of  potassium  iodide.  The  saliva  is  re- 
ceived on  filter-paper  impregnated  with  starch,  a  drop  or  two 
of  fuming  nitric  acid  is  then  added,  and  the  appearance  of  a 
blue  color  proclaims  the  presence  of  iodine.  Normally  the 
saliva  should  yield  the  reaction  for  iodine  in  from  ten  to  fif- 
teen minutes  after  the  ingestion  of  a  capsule  containing  0.1 
gramme  of  potassium  iodide.  Care  must  be  taken  that  none 
of  the  drug  adheres  to  the  outside  of  the  capsule. 

The  Motor  Pover  of  the  Stomach. — Ewald  has  sug- 
gested the  use  of  salol,  which  escapes  from  the  stomach  into 
the  intestine,  where  it  is  broken  up  into  salicylic  acid  and 
phenol.  Normally  salicyluric  acid  appears  in  the  urine  in 
from  forty  to  seventy-five  minutes  after  the  ingestion  of  one 
gramme  of  salol.  Filter-paper  moistened  with  urine  contain- 
ing salicyluric  acid  assumes  a  violet  color  when  treated  with  a 
10  per  cent,  ferric  chloride  solution. 


INDEX. 


ABDOMEN,  distention  of,  23 
Abscess,  cerebral,  350 
hepatic,  80 
perinepbritic,  106 
retropharyngeal,  30 
Acetone,  test  for,  93 
Acetomiria,  causes  of,  93 
Acholia,  73 
Acidity,  gastric,  20 

degree  of,  21 
tests  for,  497,  498 
Acids,  fatty,  in  sputum,  159 
Acue,  440 
Acromegalia,  406 
Addison's  disease,  115 
^gophony,  167 
Agraphia,  388 
Ague,  250 
Ainhum,  483 

Alse  nasi,  movement  of,  153 
Albinism,  458 
Albumin,  tests  for,  92 
Alopecia,  460 

areata,  461 
Amoeba  coli,  52 
Anaemia,  111 

.cerebral,  340 

essential,  112 

idiopathic,  112 

lymphatic,  115 

pernicious,  112 

primary,  112,  113 

symptomatic.  111 

varieties  of,  111 
Ansesthesia,  causes  of,  320 
Analgesia,  causes  of,  321 
Anchylostomum  duodenale,  64 
Aneurism,  aortic,  148 
Angina  pectoris,  147 
Angioma,  cutaneous,  474 


Anidrosis,  430 

Animal  parasites,  62 

Ankle-clonus,  319 

Anorexia,  19 

Anosmia,  154 

Anuria,  85 

Aortic  aneurism,  148 

Aortic  valves,  diseases  of,  135,  136 

Apex-beat,  119 

changes  in  the  force  of,  120 

displacement  of,  120 
Aphasia,  387 
Aphemia,  387 
Aphonia,  causes  of,  154 
Apoplexy,  cerebral,  341 

pancreatic,  69 

pulmonary,  199 
Appendicitis,  58 
Appetite,  disturbances  of,  19 
Argyll-Robertson  pupil,  328 
Argyria,  415 

Arteries,  obstruction  of  cerebral,  345 
Arthritis  deformans,  300 

rheumatoid,  300 
Arthropathies,  324 
Ascaris  lumbricoides,  63 
Ascites,  67 
Asthma,  191 
Ataxia,  locomotor,  357 
Athetosis,  316 
Atrophy,  facial,  405 

idiopathic  muscular,  369 

myopathic,  369 

muscular,  causes  of,  323 

of  liver,  acute  yellow,  84 

progressive  muscialar,  365 
Auscultation,  immediate,  166 

mediate,  166 

of  chest,  165 

of  heart,  123 

501 


502 


INDEX. 


BACILLUS,  tubercle,  159 
detection  of,  160 
Bell's  palsy,  383 
Beriberi,  381 
Bile-ducts,  catarrli  of,  73 
Bile  in  the  urine,  94 

tests  for,  94 
Blebs,  causes  of,  422 
Blood,  diseases  of,  109 

examination  of,  491 
Bothriocephalus  latus,  62 
Boulimia,  19 
Bradycardia,  126 
Brain,  abscess  of,  350 

anaemia  of,  340 

congestion  of,  339 

tumors  of,  347 
Breath,  fetor  of,  18 
Breathing,  amphoric,  166 

asthmatic,  167 

bronchial,  166 

cavernous,  166 

Cheyne-Stokes,  156 

cogged-wheel,  167 

exaggerated,  166 

in  emphysema,  167 

jerky,  167 

normal,  166 

puerile,  166 

tidal-wave,  156 

weak,  167 
Bright's  disease,  acute,  97 

chronic,  99,  100 
Bromidrosis,  431 

Bronchial  tubes,  dilatation  of,  189 
Bronchiectasis,  189 
Bronchitis,  182 

acute  catarrhal,  182 

capillary,  187 

chronic,  184 

fibrinous,  188 
Bronchophony,  167 
Bronchorrhagia,  198 
Bruit,  aneurismal,  125 
Bullae,  causes  of,  422 

CACHEXIA,  malarial,  254 
Calculus,  renal,  103 
Calculi,  biliary,  74 
Callositas,  466 
Cancer,  gastric,  42 


Cancer — 

hepatic,  81 

pancreatic,  69 
Cancrum  oris,  25 
Canities,  459 
Caput  Medusae,  416 
Carbunculus,  444 

Cardiac  dulness,  diminished  area  of, 
123 
increased  area  of,  123 
Catalepsy,  327 
Catarrh,  autumnal,  194 

biliary,  73 

bronchial,  182,  184 

gastric,  acute,  33 
chronic,  37 

intestinal,  48 

nasal,  171 

pharyngeal,  30 

suflFocative,  187 
Causalgia,  322 
Cephalalgia,  375 
Cerebro-spinal  fever,  247 
Charcot-Leyden  crystals  in  sputum, 

159 
Chest,  auscultation  of,  164 

dulness  of,  on  percussion,  165 

emphysematous,  161 

expansion  of,  163 

funnel,  162 

inspection  of,  161 

mensuration  of,  169 

palpation  of,  161 

percussion  of,  164 

phthisinoid,  161 

rachitic,  161 
Chest-walls,  oedema  of.  163 
Cheyne-Stokes  respiration,  156 
Chicken-pox,  266 
Chloasma,  464 
Chlorides  in  the  urine,  89 
Chlorosis,  113 
Cholaemia,  73 
Cholelithiasis,  74 
Cholesteraemia,  73 
Cholera,  Asiatic,  283 

infantum,  56 

morbus,  55 
Cholerine,  284 
Chorea,  Huntingdon's,  316 

minor,  396 


INDEX. 


503 


Chorea — 

insaniens,  397 
Choreiform    movements,    causes   of, 

315 
Cirrhosis,  hepatic,  77 

pancreatic,  69 
Clavus,  467 
Cold  in  the  head,  170 
Cold,  rose,  194 
Colic,  Mliary,  75 

definition  of,  21 

intestinal,  47 

mucoiis,  49 

renal,  104 
Coma,  causes  of,  325 
Comedo,  433 

Compensation  in  cardiac  disease,  135 
Conception,  imperative,  329 
Congestion,  cerebral,  339 

hepatic,  76 

pulmonary,  200 

renal,  95 
Consciousness,  disturbances  of,  325 
Consumption,  pulmonary,  216 
Contraction,  paradoxical,  320 
Convulsions,  313 

epileptiform,  313 

hysteroidal,  314 

local,  315 

salaam,  315 

tetanic,  314 

varieties  of,  313 
Cornu  cutaneum,  468 
Corpuscles,  red,  diminution  of,  109 

white,  increase  of,  109 
Coryza,  170 
Cough,  causes  of,  156 

dry,  156 

laryngeal,  157 

moist,  157 

winter,  184 
Cow-pox,  267 
Cramp,  artisans',  400 

writers',  400 
Cretinism,  351 
Crisis,  definition  of,  231 

diseases  terminating  by,  235 
Croup,  false,  176 

membranous,  177 

pseudo-membranous,  177 

spasmodic,  176 


Croup —  ' 

true,  177 
Crusts,  cutaneous,  causes  of,  426 
Cyanosis,  causes  of,  129 

congenital,  129 


DECUBITUS,  325 
Defecation,  painful,  causes  of,  22 
Degeneration,  reactions  of,  323 
Delusion,  varieties  of,  329 
Delirium,  definition  of,  329 

causes  of,  329 

tremens,  408 
Dermatalgia,  483 
Dermatitis,  451 

exfoliativa,  453 

herpetiformis,  450 
Dermatolysis,  472 
Dengue,  288 
Diabetes  insipidus,  308 

mellitus,  304 
Diacetic  acid,  tests  for,  93 
Diaceturia,  causes  of,  93 
Diarrhoea,  47 

varieties  of,  48 
Diathesis,  uric-acid,  303 
Diphtheria,  274 
Dipsomania,  408 
Disease,  Addison's,  115 

Basedow's,  402 

bleeder's,  116 

caisson,  368 

Duchenne's,  357 

Friedreich's,  362 

Graves's,  402 

Hodgkin's,  115 

Landry's,  367 

Marie's,  405 

Meniere's,  390 

Parkinson's,  398 

Raynaud's,  403 

Thomseu's,  401 
Diuresis  (see  Polyuria),  85 
Dizziness,  389 
Dropsy,  causes  of,  129 
Dysentery,  52 

amoebic,  52,  53 

catarrhal,  52 

chronic,  53 

diphtheritic,  52,  53 


504 


INDEX. 


Dysentery — 

malignant,  52,  53 
Dyspepsia,  34 

atonic,  35 

catarrhal,  37 

nervous,  35 

ECHINOCOCCUS  of  tlie  liver,  83 
Ecstasy,  327 
Ecthyma,  453 
Eczema,  446 
Eflfusion,  abdominal  (see  Ascites),  67 

pericardial,  131 

pleural,  224 
Elephantiasis,  471 
Embolism,  cerebral,  345 
Emphysema,   cutaneous,   causes   of, 
416 

pulmonary,  195 

varieties  of,  195 
Empyema  (see  Pleurisy),  225,  229 
Endocarditis,  133 

acute,  134 

chronic,  135 

malignant,  141 

sclerotic,  133 

ulcerative,  141 

vegetative,  133 
Enteritis,  acute,  48 

catarrhal,  48 

chronic,  48 

membranous,  49 
Entero-colitis,  51 
Entrorrhagia,  causes  of,  22 
Epilepsy,  385 
Epistaxis,  causes  of,  154 
Epithelioma,  cutaneous,  482 
Erysipelas,  268 
Erythema,  436 

Eruptions,  time  of  appearance  of,  233 
Exhaustion,  heat,  408 
Expectoration,  varieties  of,  157 
Eyeball,  tremor  of,  328 
Eyes,  conjugate  deviation  of,  328 


FACE,  atrophy  of,  405 
palsy  of,  383 
spasm  of,  372 


Fastigium,  definition  of,  231 
Favus,  488 
Febricula,  236 
Fecal  discharges,  22 
Festinatiou,  317 
Fever,  230 

Eestivo-antunmal,  252 

break-bone,  288 

catarrhal,  280 

causes  of,  232 

cerebro-spinal,  247 

degrees  of,  231 

detection  of,  230 

effects  of,  on  tissue,  232 

ephemeral,  236 

enteric,  237 

famine,  245 

hay,  194 

intermittent,  250 

lung,  202 

malarial,  250 

pulse-temperature,  ratio  in,  232 

relapsing,  245 

remittent,  252 

rheumatic,  290 

scarlet,  256 

simple  continued,  236 

spirillum,  245 

spotted,  247 

stages  of,  230 

symptoms  of,  232 

terminations  of,  231 

thermic,  407 

treatment  of,  232 

types  of,  331 

typhoid,  237 

typhus,  243 

yellow,  270 
Fevers,  continued,  231 

intermittent,  231 

remittent,  231 
Fibre,  elastic,  in  sputum,  158 
Fibromata,  cutaneous,  473 
Filaria  sanguineus  hominis,  64 
Floating  kidney,  107 
Fremitus,  tactile,  163 

vocal,  163 
Friction-sound,  pericardial,  125 

pleural,  224 
Furunculus,  443 


INDEX. 


505 


GAIT,  ataxic,  317 
spastic,  317 

steppage,  317 
Gall-ducts,  inflammation  of,  73 
Gall-stones,  74 

Gangrene,  symmetrical,  325,  403 
Gastralgia,  39 
Gastric  cancer,  42 

contents,  examination  of,  496 

ulcer,  40 

catarrh,  33,  37 
Gastritis,  acute,  33 

chronic,  37 
Gastrodynia,  39 
Glottis,  oedema  of,  181 

spasm  of,  179 
Glucose,  tests  for,  90 
Glycosuria,  causes  of,  90 
Goitre,  exophthalmic,  402 
Gout,  297 

latent,  303 

rheumatic,  300 
Graphospasm,  400 
Green  sickness,  113 

H^MATEMESIS,  causes  of,  45 
Hsematoidin  in  the  sputum,  159 
Hsematoma  of  the  dura  mater,  334 
Haematuria,  causes  of,  93 
HsemogloMn,  diminution  of,  110 
Hjemoglobinuria,  causes  of,  94 
Hsemopericardium,  133 
Haemophilia,  116 
Haemoptysis,  causes  of,  198 
Hair,  atrophy  of,  459 

hypertrophy  of,  470 

trophic  affections  of,  325 
Halluciuation,  329 
Hay-fever,  194 
Headache,  375 
Heart,  auscultation  of,  123 

dilatation  of,  143 

fatty  degeneration  of,  145,  146 
infiltration  of,  145 

fibroid,  142 

hypertrophy  of,  143 

inspection  of,  119 

neuralgia  of,  147 

palpation  of,  122 

percussion  of,  122 
Heart-sounds,  accentuation  of,  123 


Heart-sounds — 

reduplication  of,  124 

weakness  of,  124 
Hemiansesthesia,  causes  of,  320 
Hemi-atrophy,  facial,  405 
Hemicrania,  374 
Hemiplegia,  causes  of,  311 
Hemorrhage,  cerebral,  341 

broncho-pulmonary,  198 

from  the  intestines,  22 

from  the  kidneys,  93,  94 

from  the  lungs,  198 

from  the  nose,  154 

from  the  stomach,  45 
Hepatitis,  acute,  80 

catarrhal,  73 

interstitial,  chronic,  77 
Herpes  iris,  440 

simplex,  438 

zoster,  439 
Hiccough,  causes  of,  21 
Hives,  437 

Hodgkin's  disease,  115 
Hydatids  of  the  liver,  83 
Hydrocephalus,  334 

acute,  331 
Hydronephrosis,  106 
Hydrophobia,  288 
Hyperaemia,  cerebral,  339 

hepatic,  76 

pulmonary,  200 

renal,  95 
Hyperaesthesia,  causes  of,  322 
Hyperidrosis,  430 
Hypertrichosis,  470 
Hypertrophy,  cardiac,  143 

pseudo-muscular,  370 
Hysteria,  391 


ICHTHYOSIS,  469 
1     Icterus,  71 
Icterus  neonatorum,  72 
Ileus,  varieties  of,  59 
Illusion,  329 
Impetigo,  455 

contagiosa,  456 
Impulse,  morbid,  329 
Incubation,  periods  of,  233 
Indican,  test  for,  94 
Indicanuria,  causes  of,  94 


506 


OTDEX. 


Influenza,  280 

Insane,  general  paralysis  of,  336 

Inspection  of  the  chest,  161 

of  the  prfficordia,  119 
Intestinal  obstr action,  59 
Intussusception,  60 
Invagination,  60 
Itch,  488 

barbers',  486 


JAUNDICE,  catarrhal,  73 
causes  of,  71,  72 
hsematogenous,  72 
hepatogenous,  71 
malignant,  84 
non-obstructive,  72 
obstructive,  71 
varieties  of,  71 


KIDNEY,  amyloid  degeneration  of, 
102 
congestion  of,  95 
diseases  of,  85 
floating,  107 
gouty,  100 
inflammation  of,  acute,  97 

chronic,  99,  100 
large  white,  99 
movable,  107 
red  granular,  100 
stone  in,  103 
Tvaxy,  102 
Keloid,  473 
Keratosis  pilaris,  465 
Knee-jerk,  318 

causes  which  diminish,  318 
which  increase,  318 


T  A  GRIPPEE,  280 
Ju     Landry's  disease,  367 
Lai-yngismus  stridulus,  179 
Laryngitis,  173 
Larynx,  oedema  of,  181 
Lead-poisoning,  chronic,  412 
Lentigo,  464 
Lepra,  480 

Leptomeningitis,  cerebral,  333 
spinal,  352 


Leucin  in  the  urine,  87 
Leucocythsemia,  114 
Leucocytosis,  109 
Leucoderma,  458 
Lichen  planus,  449 

ruber,  449 

scrofulosis,  449 
Lipjemia,  111 
Lithfemia,  303 
Lithuria,  86 
Liver,  abscess  of,  80 

acute  yellow  atrophy  of,  84 

amyloid,  82 

cancer  of,  81 

cirrhosis  of,  77 

consistence  of,  70 

diminution  in  the  size  of,  71 

echinococcus  of,  83 

enlargement  of,  irregular,  71 
uniform,  71 

hydatids  of,  83 

hypersemia  of,  76 

inflammation  of,  73,  77,  80 

palpation  of,  70 

percussion,  71 

pulsation  of,  71 
Localization,  cerebral,  348 
Lockjaw,  286 
Locomotor  ataxia,  357 
Lumbago,  295 
Lungs,  abscess  of,  213 

cirrhosis  of,  211 

collapse  of,  215 

congestion  of,  200,  201 

gangrene  of,  212 

infarction  of,  199 

oedema  of,  215 
Lupus  erythematosa,  475 

vulgaris,  476 


MACROCYTOSIS,  110 
Macules,  causes  of,  417 
Malaria,  heematozoa  of,  251 

malignant,  253 
Malarial  cachexia,  250 

fever,  254 
Mania  a  potu,  408 
Measles,  260 

German,  262 
Melsena  (see  Entrorrhagia),  22 


INDEX. 


507 


Melansemia,  110 

Meniere's  disease,  390 
Meningitis,  cerebral,  331,  333,  334 

epidemic  cerebro-spinal,  247 

spinal,  352 

tuberculous,  331 
Meningo-encephalitis,  chronic,  336 
Mensuration  of  the  chest,  169 
Microcytosis,  110 
Migraine,  374 
Miliaria,  457 
Milium,  434 

Mitral  diseases,  136,  137 
MoUuscum  epitheliale,  466 
Monansesthesia,  causes  of,  321 
Monoplegia,  causes  of,  311 
Morbilli,  260 

Morbus  maculosus  Werlhofii,  117 
Morvan's  disease,  reference  to,  363 
Mouth,  diseases  of,  23 
Mucin,  spiral  of,  in  sputum,  158 
Multiple  neuritis,  381 
Mumps,  281 
Murmur,   respiratory,    modifications 

of,  166 
Murmurs,  aneurismal,  125 

cardigic,  124 

hsemic,  124 
Muscular   contraction,   paradoxical, 

320 
Myalgia,  295 
Mydriasis,  causes  of,  327 
Myelitis,  354 
Myocarditis,  142 
Myosis,  causes  of,  327 
Myotonia,  congenital,  401 
Myxcedema,  324,  404 


\T^VUS  pigmentosa,  469 

1>     Nails,  atrophy  of,  417,  480 

curving  of,  417 
Nasal  catarrh,  171 
Nematodes,  63 
Nephritis,  acute,  97 
catarrhal,  97 
parenchymatous,  97 
chronic  catarrhal,  99 
interstitial,  100 
Nephrolithiasis,  103 
Neuralgia,  371 
32 


Neurasthenia,  395 
Neuritis,  379 

multiple,  381 
Nose,  red,  causes  of,  153 
Nutrition,  disturbances  of,  322 
Nystagmus,  328 


OBSTRUCTION,  intestinal,  59 
(Edema,  causes  of,  416 

acute,  angio-neurotic,  404 
of  the  larynx,  181 
of  the  lungs,  214 

(Esophageal    obstruction,     varieties 
of,  31 

(Esophagismus,  32 

Oligocythsemia,  109 

Onychauxis,  470 

Onychia,  417 

Opium-poisoning,  411 

Oxalates  in  the  urine,  89 

Oxybutyria,  causes  of,  93 

Oxybutyric  acid,  test  for,  93 

Oxyuris  vermicularis,  64 

Ozcena,  172 


PACHYMENIN(3HTIS,  cerebral,  333 
hemorrhagic,  334 

spinal,  353 
Palpation  of  the  chest,  163 

of  the  heart,  122 
Palpitation,  128 
Palsy,  310 

Bell's,  383 

bulbar,  367 

hysterical,  391 

shaking,  398 
Pancreas,  diseases  of,  69 
Papules,  cutaneous,  causes,  424 
Parsesthesia,  322 
Paralysis,  acute  ascending,  367 

agitans,  398 

atrophic  spinal,  363 

causes  of,  310 

cerebral,  in  children,  338 

divers',  368 

glosso-labio-laryngeal,  367 

infantile,  363 

laryngeal,  155 

pseudo-hypertrophic,  370 


508 


INDEX. 


Paramyoclonus  multiplex,  316 
Paraplegia,  ataxic,  361 

causes  of,  312 

primary  spastic,  360 
Parasites,  intestinal,  62 
Paretic  dementia,  336 
Parosmia,  154 
Parotitis  (see  Mumps),  281 
Pectoriloquy,  167 
Poliosis  Eheumatica,  419 
Pemphigus,  454 
Percussion  immediate,  164 

mediate,  164 

of  the  heart,  122 

of  the  lungs,  164 
Pericarditis,  130 
Pericardium,  adherent,  131 

air  in,  133 

blood  in,  133 

dropsy  of,  132 
Peritonitis,  65 
Perityphlitis,  58 
Peruicious  anaemia,  112 
Pertussis,  278 
Petechiae,  causes  of,  418 
Pharyngitis,  29 
Phosphates  in  the  urine,  88 
Phthisis,  216 

acute,  217,  219 

fibroid,  219 

chronic  ulcerative,  217 
Pica,  19 
Pleurisy,  acute,  223 

diaphragmatic,  225 

fibrinous,  225 

hemorrhagic,  224 

purulent,  225 

tuberculous,  225 
Pleurodynia,  295 
Plumbism,  412 
Pneumonia,  alcoholic,  202 

broncho-,  207 

catarrhal,  207 

chronic  interstitial,  211 

croupous,  202 

hypostatic,  201 

in  children,  204 

lobar,  202 

senile,  204 

typhoid,  204 
Pneumopericardium,  133 


Pneumothorax,  227 

hydro-,  227 

pyo-,  227 
Poikilocytosis,  109 
Poisoning,  arsenical,  chronic,  413 

lead,  chronic,  412 

mercurial,  chronic,  413 

opium,  411 
Poliomyelitis,  acute  anterior,  363 

chronic,  365 
Polyuria,  causes  of,  85 
Pompholyx,  463 

Progressive  muscular  atrophy,  365 
Prurigo,  450 
Pruritus,  484 
Pseudo-leukaemia,  115 
Pseudo-muscular  hypertrophy,  370 
Psoriasis,  444 
Ptyalism,  25 

Pulmonary  valve,  affections  of,  138 
Pulsation,  abnormal  centres  of,  121 
Pulse,  bigeminal,  126 

Corrigan's,  128 

dicrotic,  127 

high-tension,  127 

increased  frequency  of,  125 

intermittent,  126 

irregular,  126 

jugular,  128 

low-tension,  128 

trigeminal,  126 

venous,  128 

water-hammer,  128 
Pulses,  asymmetrical  radial,  128 
Pulsus  paradoxus,  127 
Purpura  hemorrhagica,  117 
Purpuric  rashes,  causes  of,  418 
Pus  in  the  expectoration,  157 

in  the  stools,  22 

in  the  urine,  95 

in  the  vomit,  20 
Pustules,  causes  of,  422 
Pyelitis,  105 
Pyelonephritis,  105 
Pylorus,  obstruction  of,  43 
Pyonephrosis,  105 
Pyrexia,  230 
Pyuria,  causes  of,  95 


Q 


UlNSY,  26 


INDEX. 


509 


RABIES,  288 
Rachitis,  302 
Rales,  168 

Rashes,  time  of  appearance  of,  233 
Raynaud's  disease,  403 
Reflexes,  deep,  theory  of,  318 

causes  which  diminish,  318 
which  increase,  318 
superficial,  319 
Relapsing  fever,  245 
Remittent  fever,  252 
Renal  calculus  104 
colic,  104 
congestion,  95 
Resonance,  pulmonary,  diminished, 
165 
increased,  164 
outlines  of,  164 
vocal,  diminution  of,  167    . 
increase  of,  167 
Respiration,  normal,  166 

disturbances  of,  156,  166 
Respiratory  murmur,  modifications 

of,  166 
Retro-pharyngeal  abscess,  30 
Rheumatism,  acute  articular,  290 
chronic,  294 
inflammatory,  290 
muscular,  295 
Rheumatoid  arthritis,  300 
Rhinitis,  170 
Rickets,  302 
Ringworm,  485 
Romberg's  symptom,  358 
Rose  cold,  194 
Roseola,  epidemic,  262 
Rotheln,  262 
Rubella,  262 
Rubeola,  260 
Eumination,  21 

SALAAM  convulsions,  315 
Salivation  (see  Mercurial  Stoma- 
titis), 25 
Sarcinse  ventriculi,  44 
Scabies,  488 
Scales,    cutaneous,   diseases   which 

cause,  427 
Scarlatina,  256 
Scarlet  fever,  256 
Sciatica,  382 


Scleroderma,  470 

Sclerosis,  spinal,  357 

amyotrophic  lateral,  360 

disseminated,  361 

lateral,  360 

multiple,  361 

posterior,  357 
Scorbutus,  117 
Scurvy,  117 
Seborrhoea,  432 

Sensation,  disturbances  of,  320 
Sense,  muscular,  322 
Senses,  special,  disturbances  of,  327 
Sensibility,  muscular,  322 
Skin,  discolorations  of,  414 

glossy,  416 

hardness  of,  414 

paUor  of,  414 
Smallpox,  263 

Smell,  sense  of,  disturbances  of,  154 
Softening,  cerebral,  346 
Somnambulism,  327 
Sound,  cracked-pot,  165 
Sounds,  adventitious  pulmonary,  168 
Spasm,  laryngeal,  154 

cesophageal,  32 

saltatory,  315 
Spinal  cord,  sclerosis  of,  357 
Sputum,  Charcot-Leyden  crystals  in, 
159 

currant-jelly,  157 

elastic  fibre  in,  158 

fatty  acids  in,  159 

fetid,  157 

fibrinous  shreds  in,  157 

hsematoidin  in,  159 

microscopy  of,  158 

mucin  in,  158 

muco-purulent,  157 

prune-juice,  157 

purulent,  158 

rusty,  157 

spirals,  Curschmann's,  in,  192 

tubercle  bacilli  in,  160 
Stenocardia,  147 
Stomach,  cancer  of,  42 

dilatation  of,  43 

inflammation  of,  33,  37 

neuralgia  of,  39 

ulcer  of,  40 
Stomatitis,  24     ■ 


510 


INDEX. 


Stools,  changes  in,  in  disease,  22 
Steatoma,  435 
Stricture,  intestinal,  61 

oesophageal,  31 

pyloric,  43 
St.  Vitus's  dance,  396 
Siiccussion-splash,  169 
Sudamen,  431 
Sugar  in  the  urine,  90 

tests  for,  90,  91 
Sunstroke,  407 

Swallowing,  difficult,  causes  of,  19 
Sweat-glands,  diseases  of,  430 
Sycosis,  simple,  462 

tinea,  486 
Syphilis  cutanea,  478 
Syringo-myelia,  363 


TABES  dorsalis,  357 
Tachycardia,  125 
Taenia  mediocanellata,  62 

saginata,  62 

solium,  62 
Tape-worm,  varieties  of,  62 
Teeth,  Hutchinson's,  17 
Temperature,  subnormal,  causes  of, 

235 
Tetanus,  286 
Tetany,  400 

Thermo-ansesthesia,  321 
Thomsen's  disease,  401 
Thrills,  cardiac,  causes  of,  122 
Thrombosis,  cerebral,  345 
Thrush,  24 
Tic  douloureux,  372 
Tinea  circinata,  486 

favosa,  488 

sycosis,  486 

tonsurans,  485 

versicolor,  487 
Tinkling,  metallic,  169 
Tinnitus  aurium,  causes  of,  328 
Titubation,  318 
Tongue,  condition  of,  in  disease,  17 

scars  on,  18 

tremor  of,  18 
Tonsillitis,  26 
Tonsils,  hypertrophy  of,  28 
Trance,  327 
Tremors,  causes  of,  317 


Trichina  spiralis,  64 
Trichinosis,  64 
Tricocephalus  dispar,  64 
Tricuspid  valve,  diseases  of,  138 
Tumors,  cerebral,  347 

intestinal,  61 
Tubercle  bacillus,  detection  of,  159 
Tuberculosis,  acute  general,  272  . 

meningeal,  331 

pulmonary,  216 
Tubercules,  cutaneous,  causes  of,  425 
Typhlitis,  58 
Typhoid  fever,  237 
Typhus  fever,  243 
Tyrosin  in  the  urine,  87 


ULCER,  gastric,  40 
perforating,  of  the  foot,  325 
Ulcers,  cutaneous,  causes  of,  428 
Uraemia,  96 
Urates,  increase  of,  87 
Urea,  diminution  of,  86 

increase  of,  86 

test  for,  86 
Uric  acid,  test  for,  86 
Urine,  albumin  in,  92 

bile  in,  94 

blood  in,  93 

chlorides  in,  89 

chyle  in,  94 

diminution  of,  85 

increase  of,  85 

indican  in,  94 

leucin  in,  87 

oxalates  in,  89 

phosphates  in,  88 

pus  in,  95 

sugar  in,  90 

tyrosin  in,  87 

urea  in,  86 

uric  acid  in,  86 
Urobilinuria,  90 
Urticaria,  437 


YACCINIA,  267 
V     Vagabondismus,  415 
Valvular  affections  of  the  heart,  135 
Varicella,  266 
Variola,  263 


INDEX. 


611 


Varioloid,  265 

Verruca,  468 

Vertigo,  389 

Vesicles,  ciitaneous,  causes  of,  420 

Vitiligo,  458 

Vocal  cords,  paralysis  of,  155 

Voice,  loss  of,  154 

Vomit,  varieties  of,  20 

Vomiting,  causes  of,  20 


TITART,  468 


Wheals,  causes  of,  426 
Whooping-cough,  278 
Worms,  intestinal,  62 


Writers'  cramp,  400 
Wry-neck,  295 


yANTHOMA,  474 


yELLOW  fever,  270 


yOSTER,  herpes,  439 


PUBLISHED    BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  PhiladelpMa,  Pa. 


PAGE 

*American  Text-Book  of  Applied  Thera- 
peutics     7 

♦American  Text-Book  of  Diseases  of  Chil- 
dren      5 

♦American  Text-Book  of  Gynecology  ...  6 
American  Text-Book  of  Nursing  ....  7 
♦American  Text-Book  of  Obstetrics  ...  7 
♦American  Text-Book  of  Physiology  ...  7 
♦American  Text-Book  of  Practice  ....  4 
♦American  Text-Book  of  Surgery    ....    3 

Ashton's  Obstetrics        22 

Atlas  of  Skin  Diseases 10 

Ball's  Bacteriology 22 

Bastin's  Laboratory  Exercises  in  Botany  .  16 

Beck's  Surgical  Asepsis 20 

Boisliniere's    Obstetric    Accidents,   Emer- 
gencies, and   Operations 23 

Brockway's  Physics 22 

Burr's  Nervous  Diseases 20 

Cerna's  Notes  on  the  Newer  Remedies  .    .  12 
Chapman's     Medical    Jurisprudence     and 

Toxicology 20 

Cohen  and   Eshner's  Diagnosis 22 

Cragin's  Gynaecology 22 

DaCosta's  iManual  of  Surgery 20 

*De  Schweinitz's  Diseases  of  the  Eye  .    .  10 
Diet-List  and  Sick-Room  Dietary  ....  18 

Dorland's  Obstetrics 20 

Frothingham's    Guide    to    Bacteriological 

Laboratory 16 

Garrigues'  Diseases  of  Women 14 

Gleason's  Diseases  of  the  Ear 22 

Griffin's  Materia  Medica  and  Therapeutics  20 

Griffith's  Care  of  the  Baby 18 

♦Gross's  Autobiography 8 

Hare's  Physiology 22 

Hampton's    Nursing  :    its    Principles   and 

Practice 17 

Haynes'  Manual  of  Anatomy 20 

Hyde's  Syphilis  and  Venereal  Diseases  .    .  20 
Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat 22 

Jewell's  Outlines  of  Obstetrics 15 

♦Keating's     Pronouncing     Dictionary    of 

Medicine 8 

Keating's   How  to   Examine  for   Life   In- 
surance     17 


Keen's  Operation  Blanks 16 

Kyle's  Diseases  of  Nose  and  Throat   ...  20 

Laine's  Temperature  Charts 12 

Lockwood's  Practice  of  Medicine    ....  20 

Long's  Syllabus  of  Gynecology 14 

McFarland's  Pathogenic  Bacteria   ....  16 

Martin's  Surgery   . 22 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 22 

Morris'  Materia  Medica  and  Therapeutics  22 

Morris'  Practice  of  Medicine 22 

Morten's  Nurses'  Dictionary 18 

Nancrede's  Anatomy  and  Manual  of  Dis- 
section     II 

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Norris'  Syllabus  of  Obstetrical  Lectures   .  15 

Powell's  Diseases  of  Children 22 

Raymond's  Physiology 20 

Saunders'   American  Year- Book  of  Medi- 
cine and  Surgery 24 

Saunders'  Pocket  Medical  Formulary  ...  13 
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Saunders'  New  Aid  Series  of  Manuals  .  19,  20 
Saunders'  Series  of  Question  Compends  21,  22 

Sayre's  Practice  of  Pharmacy 22 

Semple's  Pathology  and  Morbid  Anatomy  22 
Semple's  Legal  Medicine,  Toxicology,  and 

Hygiene 22 

♦Senn's  Pathology  and  Treatment  of  Tu- 
mors     9 

Senn's  Syllabus  of  Lectures  on  Surgery  .  .  15 
Shaw's  Nervous  Diseases  and  Insanity  .    .  22 

Starr's  Diet  Lists  for  Children 18 

Stelwagon's  Diseases  of  the  Skin 22 

Stengel's  Manual  of  Pathology 20 

Stevens'  Materia  Medica  and  Therapeutics  12 

Stevens'   Practice  of  Medicine 11 

Stewart    and    Lawrance's    Medical    Elec- 
tricity   22 

Stoney's  Practical  Points  in  Nursing   ...  17 
Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing     20 

♦Vierordt  and   Stuart's    Medical   Diagno- 
sis      9 

♦Warren's  Surgical  Pathology 9 

Wolff's  Chemistry 22 

Wolff's   Examination  of  Urine 22 


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up  to  date  in  such  important  branches  as  cerebral,  spinal,  intestinal,  and  pelvic 
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COXTKIBUTORS : 


Dr.  Charles  H.  Burnett,  Philadelphia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charles  B.  Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  Buffalo,  N.  Y. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

William  Thomson,  Philadelphia. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 


IV.   B.   SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  ON  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
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VOIiUME   I.   COJfTAISrS ! 


Hygiene. — Fevers  (Ephemeral,  Simple  Coii- 
tinued.  Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Viccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
losis, Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOLiUME   II.  CONTAINS: 


Urine  (Chemistry  and  IMicroscopy). — Kid- 
ney and  Lungs. — Air-passages  (Larynx  and 
Bronchi)  and  Pleura. — Pharynx,  Qisophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


— Peritoneum,  Liver.and  Pancreas. — Diathet- 
ic Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithsemia,  and  Diabetes.) — ■ 
Blood  and  Spleen. — Inflammation,  Embolism,  ■ 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBITTORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  Gilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — New  York  Medical  Jourtial. 

"A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — Aytiericaii  Lancet. 

"  A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  jfournal. 


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AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  Thompson  S.  Westcott,  M.  D.  In  one  handsome  royaI-8vo 
volume  of  1190  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices :  Cloth,  $'j.oo ;  Sheep  or  Half-Morocco,  $8. 00. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  podiatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

One  decided  innovation  is  the  large  number  of  authors,  nearly  every  article 
being  contributed  by  a  specialist  in  the  line  on  which  he  writes.  This,  while 
entailing  considerable  labor  upon  the  editors,  has  resulted  in  the  publication  of 

a  work  THOROUGHLY    NEW   AND    ABREAST   OF   THE   TIMES. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

Special  chapters  embrace  at  unusual  length  the  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,  and  the  Skin;  while  the  introductory  chapters  cover  fully  the 
important  subjects  of  Diet,  Hygiene,  Exercise,  Bathing,  and  the  Chemistry  of 
Food.  Tracheotomy,  Intubation,  Circumcision,  and  such  minor  surgical  pro- 
cedures coming  within  the  province  of  the  medical  practitioner  are  carefully 
considered. 

CONTRIBUTORS : 

Dr.  Thomas  S.  Latimer,  Baltimore. 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurat,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  \V.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCosta,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards.  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
Landon  Carter  Gray,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik.  New  York. 


Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  M.  Lyman,  Chicago. 
Francis  T.  Wiles,  Baltimore. 
Charles  K.  Mills,  Philadelphia. 
John  H.  Musser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia. 
W.  P.  Northrup,  New  York. 
William  Osier,  Baltimore. 
Frederick  A.  Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York. 
William  M.  Powell,  Atlantic  City. 
B.  Alexander  Randall,  Philadelphia. 
Edward  O.  Shakespeare,  Philadelphia. 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
M.  Allen  Starr,  New  York. 
J.  Madison  Taylor,  Philadelphia. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
W.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich 
Thompson  S.  Westcott,  Philadelphia. 
Henry  R.  Wharton,  Philadelphia. 
J.  William  White,  Philadelphia. 
J.  C.  Wilson,  Philadelphia. 


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AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  Baldy,  M.  D.  Forming  a  handsome  royal-octavo  volume, 
with  360  illustrations  in  text  and  37  colored  and  half-tone  plates.  Prices : 
Cloth,  |6.oo  net;  Sheep  or  Half-Morocco,  $7.00  net. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  camber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

The  work  is  well  illustrated  throughout  with  wood-cuts,  half-tone  and 
Colored  plates,  mostly  selected  from  the  authors'  pi^ivate  collections. 


CONTRIBUTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 

Edwin  Cragin. 
^.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887,  ....  and  the  most 
complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
journal. 

"A  valuable  addition  to  the  literature  of  Gynecology.  The  writers  are  progressive, 
aggressive,  and  earnest  in  their  convictions." — Medical  News,  Philadelphia. 

"  A  thoroughly  modem  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  of  Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  of  Medical  Sciences. 


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AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  By  American 
Teachers.  Richard  C.  Norris,  A.  M.,  M.  D.,  Editor;  Robert  L. 
Dickinson,  M.  D.,  Art  Editor.  Contributors  :  James  H.  Etheridge, 
M.  D. ;  Chauncey  D.  Palmer,  M.D.;  Howard  A.  Kelly,  M.  D. ;  Charles 
Jewett,  M.  D. ;  Henry  J.  Gairigues,  M.  D. ;  Barton  Cooke  Hirst,  M.  D. ; 
Theophilus  Parvin,  M.  D. ;  George  A.  Piersol,  M.  D. ;  Edward  P.  Davis, 
M.  D. ;  Charles  Warrington  Earle,  M.  D. ;  Robert  L.  Dickinson,  M.  D. ; 
Edward  Reynolds,  M.  D. ;  Henry  Schwarz,  M.  D. ;  and  James  C.  Cam- 
eron, M.  D.  In  one  very  handsome  imperial-octavo  volume,  with  nearly  900 
illustrations,  including  full-page  plates,  and  uniform  with  "An  American 
Text-Book  of  Gynecology."  Prices:  Cloth,  $7.00  net;  Sheep  or  Half- 
Morocco,  ^8.00  net. 

Such  an  array  of  well-known  teachers  is  a  sufficient  guarantee  of  the  high 
character  of  the  work,  and  it  gives  the  assurance  that  this  work  will  have  the 
same  measure  of  success  awarded  it  as  attended  the  recent  publication  of  its 
companion  volume,  "  An  American  Text-Book  of  Gynecology." 

While  the  writers  have  each  been  assigned  special  themes  for  discussion,  the 
correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures  logical  connec- 
tion in  treatment,  the  deductions  of  which  thoroughly  represent  the  latest 
advances  in  the  science  and  elucidate  the  best  modern  methods  of  procedure. 

The  illustrations  have  received  the  most  minute  attention ;  the  cuts  interspersed 
throughout  the  text,  and  the  full-page  plates,  reflect  the  highest  attainments  of 
the  artist  and  engraver,  and  appeal  at  once  to  the  eye  as  well  as  to  the  mind  of 
the  student  and  practitioner. 

AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEUTICS. 

By  American  Teachers.  Edited  by  J.  C.  Wilson,  M.  D.,  Professor  of 
the  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Jefferson  Medical 
College,  Philadelphia.     (Nearly  Ready.) 


AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  By  American 
Teachers.  Edited  by  William  H.  Howell,  Ph.  D.,  M.  D.,  Professor 
of  Physiology,  Johns  Hopkins  University.  (In  preparation  for  early  pub- 
lication.) 

AN  AMERICAN  TEXT-BOOK  OF  NURSING.  By  American 
Teachers.     (In  preparation.) 


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A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia ;  Vice-President  of  the  American  Psediatric  Society ;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclo- 
psedia  of  the  Diseases  of  Children,"  etc. ;  and  Henry  Hamilton,  author 
of  "  A  New  Translation  of  Virgil's  yEneid  into  English  Rhyme ;"  co- 
author of  "Saunders'  Medical  Lexicon,"  etc.;  with  the  Collaboration  of 
J.  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices  :  Cloth,  ^5.00  net ; 
Sheep,  $6.00  net ;  Half- Russia,  $6.50  net,  with  Denison's  Patent  Ready- 
Reference  Index;  without  patent  index.  Cloth,  ^4.00  net;  Sheep,  $5.00  net. 
PROFESSIONAL.  OPINIONS. 
"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  iu  recommending 
it  to  my  classes." 

Henrv  M.  Lyman,  M.  D., 
Professor  of  Principles  a-,id  Practice  of  Medici7ie,  Rush  Medical  College,  Chicago,  III. 
"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LlNDSLEY,  M.  D., 
Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  University : 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn, 
"  I  will  point  out  to  my  classes  the  many  good  features  of  this  book  as  compared  with 
others,  which  will,  I  am  sure,  make  it  very  popular  with  students." 

John  Cronyn,  M.  D.,  LL.D., 
Professor  of  Priticiples  and  Practice  of  Medicine  and  Clinical  Medicine  ; 

President  of  the  p'aculiy.  Medical  Dept.  Niagara  University,  Buffalo,  N.  Y. 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumes, 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.    Price,  I5.00  net. 
This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full   and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


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SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  J.  Col- 
lins Warren,  M.  D.,  LL.D.,  Professor  of  Surgery,  Har\'ard  Medical 
School,  etc.  One  handsome  octavo  volume  of  832  pages,  with  136  illus- 
trations, T,T,  of  vvfhich  are  chromo-lithographs,  and  all  of  which  were  drawn 
from  original  specimens.   Prices:  Cloth,  $6.00  net ;  Half-Morocco,  $7.00  net. 

Covering  as  it  does  the  entire  field  of  Surgical  Patholog}'  and  Surgical  Thera- 
peutics by  an  acknowledged  authority,  the  publisher  is  confident  that  the  work 
will  rank  as  a  standard  authority  on  the  subject  of  which  it  treats.  Particular 
attention  has  been  paid  to  Bacteriology  and  Surgical  Bacteria  from  the  stand- 
point of  recent  investigations.  The  chromo-lithographic  plaies  in  their  fidelity  to 
nature  and  in  scientific  accuracy  are  incomparable. 

PATHOLOGY  AND  SURGICAL  TREATMENT  OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College ;  Professor  of  Surgery,  Chicago 
Polyclinic ;  Attending  Siurgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Prices:  Cloth,  $6.00  net; 
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This  work  epitomizes  the  results  of  many  years  of  pei-sonal  observation  and 
successful  experience  of  its  author,  whose  professional  eminence  guarantees  the 
authoritative  character  of  the  subject-matter.  The  illustrations  are  profuse  and 
unusually  fine,  including  more  than  100  original  photographic  reproductions  of 
the  microscopic  appearances  of  a  great  variety  of  morbid  conditions. 

MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Second  Enlarged  German  Edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M.  D.  Third  and  Revised  Edition.  In 
one  handsome  royal-octavo  volume  of  700  pages,  178  fine  wood-cuts  in 
text,  many  of  which  are  in  colors.  Prices  :  Cloth,  ;$4.oo  net;  Sheep,  ^5.00 
net;  Half  Russia,  $5.50  net. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as 
a  factor  in  the  origin  of  disease. 

This  valuable  work  is  now  published  in  German,  English,  Russian,  and 
Italian.  The  issue  of  a  third  American  edition  within  two  years  indicates  the 
favor  with  which  it  has  been  received  by  the  profession. 


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DISEASES  OF  THE  EYE.  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Diseases  of  the  Eye,  Phila- 
delphia Polyclinic ;  Professor  of  Clinical  Ophthalmology,  Jefferson  Medical 
College,  Philadelphia,  etc.  A  handsome  royal-octavo  volume  of  nearly  700 
pages,  with  256  fine  illustrations,  many  of  which  are  original,  and  2  chromo- 
lithographic  plates.  Prices:  Cloth,  ^4.00  net;  Sheep,  ^5.00  net;  Half- 
Russia,  I5.50  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  object  of  this  work  is  to  present  to  the  student  and  practitioner  who  is 
beginning  work  in  the  fields  of  ophthalmology  a  plain  description  of  the  optical 
defects  and  diseases  of  the  eye.  To  this  end  special  attention  has  been  paid 
to  the  clinical  side  of  the  question;  and  the  method  of  examination,  the  symp- 
tomatology leading  to  a  diagnosis,  and  the  treatment  of  the  various  ocular  defects 
have  been  brought  into  special  prominence.  The  general  plan  of  the  book  is 
eminently  practical.  Attention  is  called  to  the  large  number  of  illustrations 
(nearly  one-third  of  which  are  new),  which  will  materially  facilitate  the  thorough 
understanding  of  the  subject. 

"At  once  comprehensive  and  thoroughly  up  to  date." — Hospital  Gazette  (London). 

PROFESSIOJlTAIi  OPINIONS, 

"Contains  in  concise  and  reliable  form  the  accepted  views  of  Ophthalmic  Science." 

William  Thomson,  M.  D., 
Professor  0/  Ophthahnology ,  yeffersoji  Medical  College,  Philadelphia,  Pa. 

"  A  very  reliable  guide  to  the  study  of  eye  diseases,  presenting  the  latest  facts  and  newest 
ideas."  Swan  M.  Burnett,  M.  D., 

Professor  0/  Ophthalmology  and  Otology,  Medical  Department  Univ.  of  Georgetown, 

lVashingto7i ,  D.  C. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochronies  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  ^3.00  per  Part.     Parts  l  to  3  now  ready. 

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Hospital). 

"  The  plates  in  this  Atlas  are  remarkably  accurate  and  artistic  reproductions  of  typical 
examples  of  skin  disease.  The  work  will  be  of  great  value  to  the  practitioner  and  student." 
— William  Anderson,  M.  D.  (St.  Thomas  Hospital). 


CATALOGUE    OF  MEDICAL    WORKS.  II 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection."  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  ^2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in 
their  work  in  the  dissecting-room." — Journal  of  American  Medical  Association. 

"  Should  be  in  the  hands  of  every  medical  student." — Cleveland  Medical  Gazette. 

"  A  concise  and  judicious  work." — Buffalo  Medical  and  Surgical  Jour  nal . 


A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College 
of  Philadelphia.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations,  and  includes  the  following  sections :  General 
Diseases,  Diseases  of  the  Digestive  Organs,  Diseases  of  the  Respira^tory 
System,  Diseases  of  the  Circulatory  System,  Diseases  of  the  Nervous  Sys- 
tem, Diseases  of  the  Blood,  Diseases  of  the  Kidneys,  and  Diseases  of  the 
Skin.  Each  section  is  prefaced  by  a  chapter  on  General  Symptomatology. 
Third  edition.  Post  8vo,  502  pages.  Numerous  illustrations  and  selected 
formulae.     Price,  ^2.50. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 


12  W.   B.   SAUNDERS 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Demonstrator  of  Pathology  in  the  Woman's 
Medical  College  of  Philadelphia.     435  pages.     Price,  Cloth,  ^2.25. 

This  wholly  new  volume,  which  is  based  on  the  1890  edition  of  the  Pkarma- 
<ro/«/rt,  comprehends  the  following  sections:  Physiological  Action  of  Drugs ; 
Drugs ;  Remedial  Measures  other  than  Drugs ;  Applied  Therapeutics  ;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." — Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  gmAs."— University  Medical  Magazine. 


NOTES  ON  THE  NEWER  REMEDIES:    their  Therapeutic  Ap- 
plications and  Modes  of  Administration.     By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.      Second  edition,  revised  and  enlarged. 
^  Post-octavo,  253  pages.     Price,  ^1.25. 

SECOND  EDITION,  EE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE   CHART.     Prepared  by  D.  T.  Laine,  M.  D.      Size 
8x  13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS.  13 

SAUNDERS'  POCKET  MEDICAL  LEXICON  ;  or,  Dictionary  of 
Terms  and  Words  used  in  Medicine  and  Surgery.  By  John  M. 
Keating,  M.  D.,  editor  of  "  Cyclopaedia  of  Diseases  of  Children,"  etc. ; 
author  of  the  "New  Pronouncing  Dictionary  of  Medicine;  and  Henry 
Hamilton,  author  of  "  A  New  Translation  of  Virgil's  ^neid  into  Eng- 
lish Veise;"  co-author  of  a  "  New  Pronouncing  Dictionaiy  of  Medicine." 
A  new  and  revised  edition.  32nio,  282  pages.  Prices:  Cloth,  75  cents; 
Leather  Tucks,  ^i.oo. 

This  new  and  comprehensive  work  of  reference  is  the  outcome  of  a  demand 
for  a  more  modern  handbook  of  its  class  than  those  at  present  on  the  market, 
which,  dating  as  they  do  from  1855  to  1884,  are  of  but  trifling  use  to  the  student 
by  their  not  containing  the  hundreds  of  new  words  now  used  in  current  litera- 
ture, especially  those  relating  to  Electricity  and  Bacteriology. 

"  Remarkably  accurate  in  terminology,  accentuation,  and  definition." — Journal  of  Amer- 
ican Medical  Association. 

"  Brief,  yet  complete  ....  it  contains  the  very  latest  nomenclature  in  even  the  newest 
departments  of  medicine." — New  York  Medical  Record. 


SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1750  Formulas,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Third 
edition,  revised  and  greatly  enlarged.  Handsomely  bound  in  morocco, 
with  side  index,  wallet,  and  flap.      Price,  ^1.75  net. 

A  concise,  clear,  and  correct  record  of  the  many  hundreds  of  famous  formulae 
which  are  found  scattered  through  the  works  of  the  most  eminent  physicians 
and  surgeons  of  the  world.  The  work  is  helpful  to  the  student  and  practitioner 
alike,  as  through  it  they  become  acquainted  with  numerous  formulae  which  are 
not  found  in  text-books,  but  have  been  collected  from  among  the  rising  genera- 
tion of  the  profession,  college  professors,  and  hospital  physicians  and  surgeons. 

"  This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given  is  unusually  reliable." — New  York  Medical  Record. 

"  Designed  to  be  of  immense  help  to  the  general  practitioner  in  the  exercise  of  his  daily 
calling." — Boston  Medical  and  Surgical  Journal. 


14  JV.   B.    SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.D., 
Professor  of  Obstetrics  in  the  New  York  Post- Graduate  Medical  School 
and  Hospital;  Gynecologist  to  St.  Mark's  Hospital  and  to  the  Gennan 
Dispensary,  etc.,  New  York  City.  In  one  very  handsome  octavo  volume 
of  about  700  pages,  illustrated  by  numerous  wood-cuts  and  colored  plates. 
Prices  :  Cloth,  $4.00  net;  Sheep,  ^5.00  net. 

A  PR.A.CTICAL  work  On  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fullv  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  atiatoniyt 
of  th.&  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

EXCERPT  OF  CONTENTS. 

Development  of  the  Female  Genitals. — Anatomy  of  the  Female  Pelvic  Organs. — Phys- 
iology.—Puberty.— Menstruation  and  Ovulation.— Copulation.— Fecundation.— The  Climac- 
teric.— Etiology  in  General. — Examinations  in  General. — Treatment  in  General — Abnormal 
Menstruation  and  Metrorrhagia. — Leucorrhea. — Diseases  of  the  Vulva. — Diseases  of  the 
Perineum.— Diseases  of  the  Vagina. — Diseases  of  the  Uterus. — Diseases  of  the  Fallopian 
Tubes. — Diseases  of  the  Ovaries. — Diseases  of  the  Pelvis. — Sterility. 

The  reception  accorded  to  this  work  has  been  most  flattering.  In  the  short 
period  which  has  elapsed  since  its  issue  it  has  been  adopted  and  recommended 
as  a  text-book  by  more  than  60  of  the  Medical  Schools  and  Universities  of  the 
United  States  and  Canada. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 
Professor  of  Clinical  Gynecology ,  Medical  College  of  Ohio ;   Gynecologist  to  the  Good 
Satnaritan  and  Cincinnati  Hospitals. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
and  practical. 


CATALOGUE    OF  MEDICAL    WORKS.  1$ 


OUTLINES  OF  OBSTETRICS  :  A  Syllabus  of  Lectures  Deliv- 
ered at  Long  Island  College  Hospital.  By  Charles  Jewett,  A.  M., 
M.  D.,  Professor  of  Obstetrics  and  Pediatrics  in  the  College,  and  Obstetri- 
cian to  the  Hospital.  Edited  by  Harold  F.  Jewett,  M.  D.  Post  8vo, 
264  pages.     Price,  $2.00. 

This  book  treats  only  of  the  general  facts  and  principles  of  obstetrics  :  these 
are  stated  in  concise  terms  and  in  a  systematic  and  natural  order  of  sequence, 
theoretical  discussion  being  as  far  as  possible  avoided;  the  subject  is  thus 
presented  in  a  form  most  easily  grasped  and  remembered  by  the  student. 
Special  attention  has  been  devoted  to  practical  questions  of  diagnosis  and 
treatment,  and  in  general  particular  prominence  is  given  to  facts  which  the  stu- 
dent most  needs  to  know.  The  condensed  form  of  statement  and  the  orderly 
arrangement  of  topics  adapt  it  to  the  wants  of  the  busy  practitioner  as  a  means 
of  refreshing  his  knowledge  of  the  subject  and  as  a  handy  manual  for  daily 
reference. 

"  Rarely  has  it  been  our  fortune  to  read  a  work  of  this  nature  where,  from  the  beginning  to 
the  end,  definitions  are  so  exact  and  rules  for  guidance  so  safe." — American  Journal  of 
Obstetrics,  New  York. 

SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics  in  the  University  of  Pennsyl- 
vania. Third  edition,  thoroughly  revised  and  enlarged.  Crown  8vo. 
Price,  Cloth,  interleaved  for  notes,  ^2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "  An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  ^2.00. 

This,  the  latest  work  of  its  eminent  author,  himself  one  of  the  contributors 
to  "An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — British 
Medical  Journal,  London. 


1 6  IV.   B.    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used — viz.  general  instru- 
ments, etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  ' ' — New  York  Medical  Record 

"Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"The  plan  is  a  capital  one." — Boston  Medical  and  Surreal  yournal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  ;^2.5o. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  ilowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Specially 
written  for  students  of  medicine.  By  Joseph  McFarland,  M.  D.,  Demon- 
strator of  Pathological  Histology,  and  Lecturer  on  Bacteriology,  in  the 
Medical  Department  of  the  University  of  Pennsylvania.  Price,  Cloth, 
$2.50  net. 

A  concise  account  of  the  technical  procedures  necessary  in  the  study  of  Bac- 
teriology.     Finely  illustrated. 

A  GUIDE  TO  THE  BACTERIOLOGICAL  LABORATORY.     By 

Langdon  Frothingham,  M.  D.     Illustrated.     Price,  75  cents.. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work. 


CATALOGUE    OF  MEDICAL    WORKS.  I J 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Psediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate 
the  text.     Second  edition.     Price,  Cloth,  ^2.00  net. 

Part  I.,  carefully  prepared  from  the  best  works  on  Physical  Diagnosis,  gives  a 
succinct  account  of  the  methods  used  in  making  examinations,  and  a 
description  of  the  normal  condition  and  of  the  earliest  evidences  of  disease. 

Part  II.  contains  the  Instructions  of  twenty-four  Life-Insurance  Companies  to 
their  medical  examiners. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 


NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel 
Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  484 
pages,  profusely  illustrated.     Price,  Cloth,  ^2.00  net. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-school 
for  Nurses,  Lawrence,  Massachusetts ;  Superintendent  of  Training-school 
for  Nurses,  Carney  Hospital,  South  Boston.  i2mo.,  400  pages.  Price, 
Cloth,  $1.75  net. 

A  vade  ?nea-t?n  for  the  private  nurse,  and  an  efficient  teaching-book  for  train- 
ing-schools. A  valuable  feature  is  the  instructions  for  quickly  improvising 
needed  sick-room  appliances. 


IV.   B.    SAUNDERS' 


THE  CARE  OF  THE  BABY.  By  J.  P.  Crozkr  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  and  Instructor  in  Clinical 
Medicine,  Medical  Department  University  of  Pennsylvania;  Physician  to 
St.  Agnes',  Howard,  St.  Clement's,  and  the  Children's  Hospitals,  Phila- 
delphia, etc.  392  pages,  with  67  illustrations  in  the  text,  and  5  plates. 
l2mo.     Price,  ^1.50. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  Compiled 
for  the  use  of  nurses.  By  HoNNOR  Morten,  author  of  "  How  to  Become 
a  Nurse,"  "  Skelches  of  Hospital  Life,"  etc.  i6mo,  140  pages.  Price, 
Cloth,  ^i.oo. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital ;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  $\.^o    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
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sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
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disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  ^1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life ;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
for  the  preparation  of  diluents  and  foods  are  appended. 


Practical,  Exhaustive,  Autlioritative. 


SAUNDERS' 

NEW  AID  SERIES  OF  MANUALS 

FOR 

Students  and  Practitioners. 


Mr.  Saunders  is  pleased  to  announce  as  now  ready  his  NEW  AID 
SERIES  OF  MANUALS  for  Students  and  Practitioners.  As  pub- 
lisher of  the  Standard  Series  of  Question  Compends,  and  through  intimate 
relations  with  leading  members  of  the  medical  profession,  Mr.  Saunders  has 
been  enabled  to  study  progressively  the  essential  desiderata  in  practical  "  self- 
helps  "  for  students  and  physicians. 

This  study  has  manifested  that,  while  the  published  "  Question  Compends" 
earn  the  highest  appreciation  of  students,  whom  they  serve  in  reviewing  their 
studies  preparatory  to  examination,  there  is  special  need  of  thoroughly  reliable 
handbooks  on  the  leading  branches  of  Medicine  and  Surgeiy,  each  subject 
being  compactly  and  authoritatively  written,  and  exhaustive  in  detail,  without 
the  introduction  of  cases  and  foreign  subject-matter  which  so  largely  expand 
ordinary  text-books. 

The  Saunders  Aid  Series  will  not  merely  be  condensations  from 
present  literature,  but  will  be  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative 
American  Colleges.  This  new  sei-ies,  therefore,  will  form  an  admirable 
collection  of  advanced  lectures,  which  will  be  invaluable  aids  to  students  in 
reading  and  in  comprehending  the  contents  of  "  recommended "  works. 

Each  Manual  will  further  be  distinguished  by  the  beauty  of  the  7tew  type ; 
by  the  quality  of  the  paper  and  printing ;  by  the  copious  use  of  illustrations ; 
by  the  attractive  binding  in  cloth ;  and  by  their  extremely  low  prices. 

19 


SAUNDERS'  NEW  AID  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.  D.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital,  etc.     Price,  ^1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D,,  Demonstrator  of  Surgery,  Jefferson  Medical  College,  Philadelphia, 
etc.     Double  number.     Price,  ^2.50  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION- WRITING. 

By  E.  Q.  Thornton,    M.  D.,  Demonstrator   of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc,     Price,  ^1.50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  ^^1.25  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.  D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     (Double  number.)     Price,  ^2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases,  in  Rush  Medical  College,  Chicago.  (Double  number.) 
Price,  ^2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New 
York  Infirmary,  etc.     (Double  number.)     Price,  ^2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Asst.  Demonstrator 
of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological  Dispen- 
sary, Pennsylvania  Hospital.      (Double  number.)     Price,  ^2.50  net. 

VOLUMES  IN  PPv,EPABATION. 

MATERIA  MEDICA  AND  THERAPEUTICS.  By  Henry  A. 
Griffin,  A.  B.,  M.  D.,  Assistant  Physician  to  the  Roosevelt  Hospital, 
Out- Patient  Department,  New  York  City. 

NERVOUS  DISEASES.  By  Charlp:s  W.  Burr,  M.  D.,  Clinical  Pro- 
fessor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.  D.,  Chief  Laryngolo- 
gist  to  St.  Agnes'  Hospital,  Philadelphia ;  Instructor  in  Clinical  Microscopy 
and  Assistant  Demonstrator  of  Pathology  in  Jefferson  Medical  College. 

PATHOLOGY.     By  Alfred  Stengel,  M.  D.,  Instructor  in  Clinical  Medi- 
cine, Medical  Department,  University  of  Pennsylvania. 
*s.*  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-pre- 
pared works  on  the  subjects  of  Anatomy,  Gynecology,  Hygiene,  etc.,  by  prom- 
inent specialists. 


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THE   REASON   ^A^HY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  do  help;  they  are 
the  leaders  in  their  special  line,  well  arid  authoritatively  written  by  able  men, 
who,  as  teachers  in  the  large  colleges,  know  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty-four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessary,  many  of  them  being  in  their  fourth  and 
iifth  editions. 

TO   SUM   UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

***  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  over 
for  List). 


SAUNDERS'  QUESTION-COMPEND  SERIES. 

Price,  Cloth,  $1.00  per  copy,  except  when  otherwise  noted. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     3d  edition.     Illustrated.      Re- 

vised and  enlarged  by  H.  A.  Hare,  M.  D      (Price,  |i.oo  net.) 

2.  ESSENTIALS  OF  SURGERY.     5th  edition,  with  an  Appendix  on 

Antiseptic  Surgery.     90  illustrations.     By  Edward  Martin,  M.  D. 

3.  ESSENTIALS  OF  ANATOMY.    5th  edition,  with  an  Appendix.     180 

illustrations.     By  Charles  B.  Nancrede,  M.  D. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND 

INORGANIC.  4th  edition,  revised,  with  an  Appendix.  By  Law- 
rence Wolff,  M.  D. 

5.  ESSENTIALS    OF    OBSTETRICS.     3d    edition,   revised    and    en- 

larged.    75  illustrations.     By  W.  Easterly  Ashton,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY. 

6th  thousand.     46  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA    MEDICA,    THERAPEUTICS, 

AND  PRESCRIPTION- WRITING.  4th  edition.  By  Henry 
Morris,  M.  D. 

8.  9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.     By  Henry 

Morris,  M.  D.  An  Appendix  on  Urine  Examination.  Illustrated. 
By  Lawrence  Wolff,  M.  D.  3d  edition,  enlarged  by  some  300  Es- 
sential Formulse,  selected  from  eminent  authorities,  by  Wm.  M.  Powell, 
M.  D.     (Double  number,  price  ^2.00.) 

10.  ESSENTIALS  OF  GYN.^COLOGY.     3d  edition,  revised.     With 

62  illustrations.     By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES   OF  THE  SKIN.     3d  edition,  re- 

vised and  enlarged.  71  letter-press  cuts  and  15  half-tone  illustrations. 
By  Henry  W.  Stelwagon,  M.  D.     (Price,  ^i.oo  net.) 

12.  ESSENTIALS   OF  MINOR  SURGERY,  BANDAGING,  AND 

VENEREAL  DISEASES.  2d  edition,  revised  and  enlarged.  78 
illustrations.     By  Edward  Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND 

HYGIENE.     130  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF  THE  EYE,  NOSE,  AND 

THROAT.  124  illustrations.  2d  edition,  revised.  By  Edward 
Jackson,  M.  D.,  and  E.  Baldwin  Gleason,  M.  D. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     4th  thousand. 

By  William  H.  Powell,  M.  D. 

16.  ESSENTIALS     OF    EXAMINATION     OF    URINE.       Colored 

"  VoGEL  Scale,"  and  numerous  illustrations.  By  Lawrence  Wolff, 
M.  D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis-Cohen,  M.  D.,  and 

A.  A.  Eshner,  M.  D.     55  illustrations,  some  in  colors.    (Price,  ^1.50  net.) 

18.  ESSENTIALS    OF    PRACTICE    OF   PHARMACY.     By  L.   E. 

Sayre.     2d  edition,  revised. 

20.  ESSENTIALS    OF    BACTERIOLOGY.     2d  edition.     81    illustra- 

tions.    By  M.  V.  Ball,  M.  D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY. 

48  illustrations.     2d  edition,  revised.     By  John  C.  Shaw,  M.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.     2d 

edition,  revised.     By  Fred  J.  Brockway,  M.  D.     (Price,  ^i.oo  net.) 

23.  ESSENTIALS  OF  iviEDICAL  ELECTRICITY.     65  illustrations. 

By  David  D.  Stewart,  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     By  E.  B.  Glea- 

son, M.  D.     89  illustrations. 


RECENT   PUBLICATIONS. 


AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.  D. ,  Professor  of  Physiology  in  the 
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AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEUTICS. 

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Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College.  One  handsome  octave  volume 
of  1326  pages.  Illustrated.  Prices:  Cloth,  ^7.00  net;  Sheep  or  Half- 
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A   TEXT-BOOK    OF    MATERIA    MEDICA,    THERAPEUTICS, 

AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.  G.,  M.  D., 

Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians  and  Surgeons,  Chicago,  etc.  8vo,  858  pages.  Illustrated. 
Prices  :  Cloth,  §;4.oo  net ;  Sheep  or  Half-Morocco,  $5.00  net. 

A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
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C.  M.,  Edin.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and 
174  beautifully  colored  original  illustrations.  Price,  strongly  bound  in 
Cloth,  S6.00  net. 

ESSENTIALS  OF   PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwix,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diag- 
nosis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laiyngology,  and 
Diseases  of  the  Chest.  200  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  Si. 25  net. 

ARCHIVES  OF  CLINICAL  SKIAGRAPHY.  By  Sydney  Rowland, 
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illustrating  the  applications  of  the  new  photography  to  Medicine  and  Sur- 
gery.    Price,  per  Part,  $1.00.     Parts  I.  and  II.  now  ready. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisliniere,  M.  D.,  late  Emeritus  Professor  of  Ob- 
stetrics in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  $2.00  net. 

WATER  AND  WATER  SUPPLIES.  By  John  C.  Thresh,  D.  Sc, 
M.  B.,  D.  P.  H.  i2mo,  438  pages,  illustrated.  Handsomely  bound  in 
Cloth,  with  gold  side  and  back  stamps.     Price,  $2.25  net. 


NOW  READY,  VOLUME  FOR  1896. 


^ 


AMERICAN  YEAR-BOOK  OF  MEDICINE  and  SURGERY. 

Edited   by  GEORGE  M.  GOULD,  A.M.,  M.  D. 
Assisted  by  Eminent  American  Specialists  and  Teachers. 


<»  — 

^         Notwithstanding  the  rapid  multiplication  of  medical  and  surgical  works, 

5  still  these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician,  5 

^  inasmuch  as  he  feels  the  need  of  something  more  than  mere  text -books  of  well-  "^1 

"^  known  principles  of  medical  science.     Mr.  Saunders  has  long  been  impressed  ^ 

^  with  this  fact,  which  is  confirmed  by  the  unanimity  of  expression  from  the  pro-  ^ 

sj  fession  at  large,  as  indicated  by  advices  from  his  large  corps  of  canvassers.  ^ 

fe        This  deficiency  would  best  be  met  by  current  journahstic  literature,  but  most  2; 

"Sg  practitioners  have  scant  access  to  this  almost  unlimited  source  of  information,  «. 

2  and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many  ^ 

•»  interesting  cases  whose   study  would  doubtless  be  of  inestimable  value  in  his  ;; 

^  practice.     Therefore,  a  work  which  places  before  the  physician  in  convenient  tt. 

,^  form  an  epitomization  of  this  liferatwe  by  persons  competent  to  pronounce  upon  ^ 

«*                The  Value  of  a  Discovery  or  of  a  Method  of  Treatment  ?*. 

«  cannot  but  command  his  highest  appreciation.     It  is  this  critical  and  judicial  2 

.5  function  that  will  be  assumed  by  the  Editorial  staff  of  the  "  American  Year- 

'^  Book  of  Medicine  and  Surgery."  « 

5*         It  is  the  special  purpose  of  the  Editor,  whose  experience  peculiarly  qualifies  «. 

jg  him  for  the  preparation  of  this  work,  not  only  to  re\-iew  the  contributions  to  (^ 

American  journals,  but  also  the  methods  and  discoveries  reported  in  the  leading  J 


^    medical   journals  of  Europe,  thus  enlarging;  the  survev  and  making  the  work 

5     characteristicallv  international.     These  reviews  will  not  simply  be  a  series  of 
w^  - 

*  undigested  abstracts  indiscriminately  iiin  together,  nor  will  they  be  retrospective 

^  of  "  news  "  one  or  two  years  old,  but  the  treatment  presented  will  be  syjtihetic 

•^  and  dogmatic,  and  will  include  only  what  is  new.      Moreover,  through  expert 

i  condensation  by  experienced  writers  these  discussions  will  be 

Comprised  in  a  Single  Volume  of  about  1200  Pages. 
The  work  will  be  replete  with  original  and  selected  illustrations  skilfully 
reproduced,  for  the  most  part  in  Mr.  Saunders'  own  studios  established  for  the 
purpose,  thus  ensuring  accuracy  in  delineation,  atfording  efiicient  aids  to  a  right 
comprehension  of  the  text,  and  adding  to  the  attractiveness  of  the  volume. 
Prices:  Cloth,  ^6.50  net ;  Half  Morocco,  S7. 50  net. 

W.   B.   SAUNDERS,   Publisher, 

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JUST   ISSUED. 

PENROSE'S  DISEASES  OF  WOMEN. 

A  Text=Book  of  Diseases  of  Women.    By  Charles  B.  Penrose,  M.  D.,  Ph.  D., 

Professor  of  Gynecology,  University  of  Pennsylvania;  Surgeon  to  the  Gynecean 
Hospital,  Philadelphia.  Octavo  volume  of  -529  pages,  handsomely  illustrated. 
Price,  S3.50  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  By  Frank  B.  Mallory,  A.M.,  M.D.,  Asst.  Professor 
of  Pathology,  Harvard  Medical  School;  and  James  H.  Wright,  A.  M.,  M.  D.,  In- 
structor in  Pathology,  Harvard  Medical  School.  Octavo  volume  of  396  pages, 
handsomely  illustrated.    Price, 

SENN'S  GENITO=URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito=Urinary  Organs,  Male  and  Female.  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College,  Chicago.     Handsome  octavo  volume  of  320 

pages. "  Illustrated.    Price, 


SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Suttox,  F.  R.  C.  S.,  Asst.  Surgeon  to  Middle 
sex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London  ;  and  ARTHt'R  E.  Giles 
M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S.  Edin.,  Asst.  Surgeon  to  Chelsea  Hospital,  London 
436  pages,  handsomely  illustrated.    Price,  82.50  net. 


IN  PREPARATION. 

ANDERS'  PRACTICE  OF  MEDICINE. 

A  Text=Book  of  the  Practice  of  Medicine.    By  James  M.  Anders,  M.  D.,  Ph.  D., 

LL.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Medico- 
Chirurgieal  College,  Philadelphia.    In  press. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D.,  Professor  of 
the  Practice  of  Surgery  and  of  Clinical" Surgery,  Minneapolis  College  of  Physi- 
cians and  Surgeons.    In  press. 

AN  AMERICAN  TEXT  BOOK  OF  GENITO=URINARY  AND  SKIN 
DISEASES, 

EditedbyL.  Bolton  Bangs,  M.  D.,  Late  ProfessorofGenito-Urinarv  and  Venereal 
Diseases,  New  York  Post-Graduate  Medical  School  and  Hospital,  and  William 
A.  Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical  College. 

AN   AMERICAN   TEXT=BOOK   OF    DISEASES   OF  THE   EYE, 
EAR,   NOSE,   AND  THROAT. 

Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of  Ophthalmology  in  the  Jeffer- 
son Medical  College,  and  B.  Alexander  Randall,  M.  D.,  Professor  of  Diseases 

of  the  Ear  in  the  University  of  Pennsylvania. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor  of  Obstet- 
rics, University  of  Pennsylvania. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Professor  of 
Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of  Minnesota, 
College  of  Medicine  and  Surgerj\ 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Prosector  to  the  Pro- 
fessor of  Anatomy,  Medical  Department,  University  of  Pennsylvania. 


JSfOJV  HEADY,    VOLUMES  FOB  ISiHi  AND    1897. 


'« 


SA-XJIsriDES^S' 

AMERICAN  YEAR-BOOK  OF  MEDICINE  and  SURGERY, 

Edited   by  GEORGE  M.  GOULD,  A.M.,  M.  D. 
Assisted  by  Eminent  American  Speciali&ts  and  Teachers. 


Notwithstanding  the  rapid  multiplication  of  medical  and  surgical  works, 
still  these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician, 
inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-books  of  well- 
known  principles  of  medical  science.  Mr.  Saunders  has  long  been  impressed 
with  this  fact,  which  is  confirmed  by  the  unanimity  of  expression  from  the  pro- 

5  fession  at  large,  as  indicated  by  advices  from  his  large  corps  of  canvassers. 

6  This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most 
"55  practitioners  have  scant  access  to  this  almost  unlimited  source  of  information, 
^  and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many 
g  interesting  cases  whose  study  would  doubtless  be  of  inestimable  value  in  his 
O  practice.  Therefore,  a  work  which  places  before  the  physician  in  convenient 
^  form  an  epitomization  of  this  literature  by  persons  competent  to  pronounce  upon 
§  The  Value  of  a  Discovery  or  of  a  Method  of  Treatment 

«  cannot  but  command  his  highest  appreciation.  It  is  this  critical  and  judicial 
.^  function  that  will  be  assumed  by  the  Editorial  staff  of  the  "  American  Year- 
f^     Book  of  Medicine  and  Surgery." 

g  It  is  the  special  purpose  of  the  Editor,  whose  experience  peculiarly  qualifies 
§  him  for  the  preparation  of  this  work,  not  only  to  review  the  contril)utions  to 
•  American  journals,  but  also  the  methods  and  discoveries  reported  in  the  leading 
fe  medical  journals  of  Europe,  thus  enlarging  the  survey  and  making  the  work 
«)  characteristically  international.  These  reviews  will  not  simply  be  a  series  of 
^  undigested  abstracts  indiscriminately  run  together,  nor  will  they  be  retrospective 
g  of  "  news  "  one  or  two  years  old,  but  the  treatment  presented  will  be  synthetic 
"^  and  dogmatic,  and  will  include  only  what  is  new.  Moreover,  through  expert 
2     condensation  by  experienced  writers  these  discussions  will  be 

Bh 

Comprised  in  a  Single  Volume  of  about  1200  Pages. 

The  work  will  be  replete  with  original  and  selected  illustrations  skilfully 

reproduced,  for  the  most  part  in  Mr.  Saunders'  own  studios  established  for  the 

purpose,  thus  ensuring  accuracy  in  delineation,  affording  efficient  aids  to  a  right 

comprehension   of  the  text,  and   adding  to  the  attractiveness  of  the  volume. 

Prices:  Cloth,  ^6.50  net ;  Half  Morocco,  ^7.50  net. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  Street,  Philadelphia. 


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